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Antibiotic susceptibility, heteroresistance, and updated treatment strategies in Helicobacter pylori infection

Authors Mascellino MT, Porowska B, De Angelis M, Oliva A

Received 6 March 2017

Accepted for publication 23 May 2017

Published 28 July 2017 Volume 2017:11 Pages 2209—2220

DOI https://doi.org/10.2147/DDDT.S136240

Checked for plagiarism Yes

Review by Single-blind

Peer reviewers approved by Dr Akshita Wason

Peer reviewer comments 2

Editor who approved publication: Dr Sukesh Voruganti

Video abstract presented by Professor Maria Teresa Mascellino.

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Maria Teresa Mascellino,1 Barbara Porowska,2 Massimiliano De Angelis,1 Alessandra Oliva1

1Department of Public Health and Infectious Diseases, 2Department of Cardio-Thoracic, Vascular, General Surgery and of Organ Transplants, Policlinico Umberto I, Rome, Italy

Abstract: In this review, we discuss the problem of antibiotic resistance, heteroresistance, the utility of cultures and antibiotic susceptibility tests in Helicobacter pylori (Hp) eradication, as well as the updated treatment strategies for this infection. The prevalence of antibiotic resistance is increasing all over the world, especially for metronidazole and clarithromycin, because of their heavy use in some geographical areas. Heteroresistance (simultaneous presence of both susceptible and resistant strains in different sites of a single stomach) is another important issue, as an isolate could be mistakenly considered susceptible if a single biopsy is used for antimicrobial tests. We also examined literature data regarding eradication success rates of culture-guided and empiric therapies. The empiric therapy and the one based on susceptibility testing, in Hp eradication, may depend on several factors such as concomitant diseases, the number of previous antibiotic treatments, differences in bacterial virulence in individuals with positive or negative cultures, together with local antibiotic resistance patterns in real-world settings. Updated treatment strategies in Hp infection presented in the guidelines of the Toronto Consensus Group (2016) are reported. These suggest to prolong eradication therapy up to 14 days, replacing the old triple therapy with a quadruple therapy based on proton pump inhibitor (PPI), bismuth, metronidazole, and tetracycline for most of the patients, or as an alternative quadruple therapy without bismuth, based on the use of PPI, amoxicillin, metronidazole, and clarithromycin. The new drug vonoprazan, a first-in-class potassium-competitive acid blocker recently approved in Japan, is also considered to be a promising solution for Hp eradication, even for clarithromycin-resistant strains. Furthermore, there is growing interest in finding new therapeutic strategies, such as the development of vaccines or the use of natural resources, including probiotics, plants, or nutraceuticals.

Keywords:
eradication, biopsies, rescue

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