The increasing antimicrobial resistance of Helicobacter pylori in Iran: A systematic review and meta‐analysis

Abstract

Background Antimicrobial resistance of Helicobacter pylori can result in eradication failure. Metadata on the antimicrobial resistance of H pylori in Iran could help to formulate H pylori eradication strategies in Iran. Methods A systematic review was performed after searching in MEDLINE, Scopus, Embase, Web of Science, and the Cochrane Library. A meta‐analysis was performed, and a comparison of the rates between children and adults; time periods (1999‐2010, 2011‐2016, 2017‐2019); and the methods used was carried out. Results A total of 66 studies investigating 5936 H pylori isolates were analyzed. The weighted pooled resistance (WPR) rates were as follows: clarithromycin 21% (95% CI 16‐26), metronidazole 62% (95% 57‐67), clarithromycin in combination with metronidazole 16% (95% CI 10‐23), ciprofloxacin 24% (95% CI 15‐33), levofloxacin 18% (95% CI 9‐30), erythromycin 29% (95% CI 12‐50), furazolidone 13% (95% CI 4‐27), tetracycline 8% (95% CI 5‐13), and amoxicillin 15% (95% CI 9‐22). During the three time periods, there was an increased resistance to amoxicillin, clarithromycin, ciprofloxacin, furazolidone, and tetracycline (P ˂ .05). Furazolidone and a clarithromycin/metronidazole combination had the higher resistance rates in children (P ˂ .05). Conclusion An increasing rate of resistance to amoxicillin, clarithromycin, ciprofloxacin, furazolidone, and tetracycline in Iranian H pylori isolates was identified. In children, the resistance to furazolidone and a combination of clarithromycin and metronidazole is higher compared to adults. As a stable, high resistance to metronidazole was found in children and adults in all Iranian provinces, we suggest that metronidazole should not be included in the Iranian H pylori eradication scheme.

Helicobacter pylori: a systematic review of drug resistance in Iran

“…In a review conducted in Iran in 2015 [30] to evaluate the resistance of H. pylori, out of 1553 samples, 956 samples (61.6%) showed resistance to metronidazole. In 2017 [29], out of 926 samples, 58% were resistant to metronidazole, and finally in 2020 [31], out of 4330 samples, 62% of the samples were resistant to this antibiotic. This indicates the relatively stable resistance of H. pylori in recent years in Iran.…”

“…The prevalence of H. pylori resistance to amoxicillin and tetracycline in different geographical areas is 0-30% and 0-10%, respectively [34]. With increasing antibiotic resistance of H. pylori, it is recommended to replace the treatment of quadruple bismuth (treatment including proton-pump inhibitor (PPI), bismuth, metronidazole, and tetracycline) with a triple treatment based on clarithromycin in the first line of eradication of H. pylori [31]. Molecular genetic testing may estimate the prevalence of resistance higher than phenotypic testing because it more accurately detects populations mixed with resistant and sensitive kettles although the unclear clinical relevance of heteroresistance should be [35,36].…”

Clarifying varied Helicobacter pylori eradication therapies: A comprehensive review

“…[58][59][60]73,74 However, studies have revealed alarmingly high amoxicillin resistance rates exceeding 15% in Iran, which suggests the need for cautious application of the HDDT regimen in such regions. 75 In situations characterized by low amoxicillin resistance, meticulous consideration must be given to the dosage of amoxicillin when implementing dual therapy. An RCT conducted in China compared the effectiveness of a low-dose dual therapy with a HDDT in treatment-naïve patients (vonoprazan 20 mg and amoxicillin 1000 mg, administered either twice daily or thrice daily).…”

“…pylori strains 58–60,73,74 . However, studies have revealed alarmingly high amoxicillin resistance rates exceeding 15% in Iran, which suggests the need for cautious application of the HDDT regimen in such regions 75 …”

Antibiotic resistance in Helicobacter pylori: From potential biomolecular mechanisms to clinical practice

“…According to existing reports, the TET‐resistance rate in H. pylori is generally at a low level in most regions of the world. In Asia, it has been reported that the TET‐resistance rates are 1.18% in China, 12 0.6% in Bhutan, 89 8% in Iran, 90 5.3% in India, 63 and 2% in Japan 11 . In Europe, the total TET‐resistance rate was below 1%, 14 and that in Germany was 2.5% 66 .…”