Open access peer-reviewed chapter

Gastric Microbiota and Resistance to Antibiotics

Written By

Agnes Tving Stauning, Rie Louise Møller Nordestgaard, Tove Havnhøj Frandsen and Leif Percival Andersen

Submitted: March 9th, 2018 Reviewed: August 1st, 2018 Published: November 5th, 2018

DOI: 10.5772/intechopen.80662

Chapter metrics overview

1,059 Chapter Downloads

View Full Metrics

Abstract

Studies on gastric microbiota find several bacterial families and species in the stomach using molecular-based techniques. When biopsies are cultured, there may be growth of bacteria, pure culture of Helicobacter pylori, or no growth. When looking at the histological sections of corresponding biopsies no bacteria may be seen, except curved rods (H. pylori) adherent to the gastric epithelial cells. In a number of biopsies, several different bacteria are cultured with or without H. pylori. The non–H. pylori bacteria cultured are like the normal oral flora and may be contamination of the samples during endoscopy. In histological sections, these bacteria are seen above the mucin layer and not adherent to the epithelial cells confirming that it is contamination of the samples and can thus not be regarded as gastric microbiota. Therefore, the susceptibility of H. pylori to antibiotics is independent of coexisting bacterial flora. A review of H. pylori susceptibility to antibiotics in untreated and previous treated patients will be given including meta-analyses of H. pylori susceptibility to metronidazole (MTZ), clarithromycin, and levofloxacin. These data indicate that these antibiotics become more doubtful to use for primary therapy and should be banned for secondary therapy without susceptibility testing.

Keywords

  • gastric microbiota
  • H. pylori
  • histology
  • susceptibility testing
  • resistant rates

1. Introduction

Microbiota and microbiome are not always clearly defined or distinguished. The human microbiota comprises the population of microbial species that live on or in the human body. This is the resident flora of the body and does not include the transient flora (sampling contamination, etc.). The microbiome is constituted by all the genes inside these microbial cells and is thus restricted to detection by molecular methods (sequencing, polymerase chain reactions [PCR]) [1].

By molecular methods, bacteria are usually identified to family and genera level [2]. Bacterial families and genera may include species and types of bacteria that may have completely opposite actions in the human body [3]. It is, therefore, doubtful if molecular methods alone are sensitive enough to predict the effect of the composition of microbiota. The limited original literature on gastric microbiota has mainly focused on gastric cancer and contains conflicting results [4, 5, 6, 7]. There are many difficulties in investigating the gastric microbiota. One thing many authors are not aware of is the difficulty of getting samples without contaminating bacterial flora (Figure 1) [8]. In animal models, the whole stomach can be removed, and contamination of the stomach can be avoided, but in most animal species, physiology, acidity, etc. of the stomach are very different from the human stomach. Samples from the human stomach are usually taken as biopsies during gastroscopy. Even though the endoscope and the forceps are sterilized or decontaminated, it will be contaminated with oral bacterial flora during gastroscopy and thereby will the samples be contaminated by oral flora mainly of the phyla Firmicutes[8, 9].

Figure 1.

Schematic illustration of the gastric mucosa with the main cell types of oxyntic and pyloric glands in the gastric epithelium. Gastric stem cells reside in the isthmus zone of the gland and differentiate into precursors of the different cell lineages, which migrate either apically toward the gastric lumen or downwards to the base. The superficial epithelium and the gastric glands are covered by a viscous mucus layer mainly composed of MUC5AC, secreted by the SMCs, and MUC6, secreted mainly by MNCs and antral gland cells. The mucus layer consists of an inner layer, which is firmly attached to the epithelium, and an outer loose layer. The gastric pathogenHelicobacter pylorihas been shown to use the transmucus pH gradient between the acidic gastric lumen and the near‐neutral epithelial surface for spatial orientation to reach its niche at the juxtamucosal epithelium. The precise location of non–H. pylorimicrobiota is still hypothetical. [8].

Bacterial resistance to antibiotics can occur either if the bacteria obtain plasmids containing resistance genes from other bacteria in the microbiota (conjugation); they can take up free DNA with resistance genes from the environment (transcription) or DNA can be transferred by bacteriophages (transduction). Furthermore, mutations can occur in the bacterial genome which may result in resistance if the mutation occurs in the part of the genome that codes for a structure on which the antibiotics act; this action may be interfered, and the bacteria becomes resistant to the antibiotic [10, 11, 12]. The conjugation of plasmids increases with the number of different bacteria in the microbiota and depends on a close contact between the bacteria. Uptake of free DNA does not demand a direct contact with other bacteria, but bacteria should probably be present in the close environment [3]. Mutations occur in all bacteria with a certain time because of natural replication errors [12]. Some bacteria mutate more often than others; but because of the short generation time for bacteria, each bacterial clone will have several mutations. If the mutation occurs in a part of the genome, which is target for the antibiotics, resistance to the antibiotic may occur.

Advertisement

2. Study on gastric microbiota

In a previous unpublished study that included 411 biopsies from patients undergoing upper gastrointestinal endoscopy were investigated both by microaerobic culture and by histology (Table 1). From 249 (60%) biopsies other bacteria than H. pyloriwere cultured. These bacteria were oral flora, that is, Streptococcusspp., Staphylococcusspp., Corynebacteriumspp., Neisseriaspp., etc., which may indicate contamination of both the endoscope and the biopsies during the procedure. In histological sections, very few bacteria except H. pyloriwere seen in 20 (5%) of the biopsies. In all cases, the bacteria were located superficial to the mucus layer and not in relation to the epithelial cells and H. pylori, which confirm that it is contamination from the oral cavity. The discrepancy in the number of biopsies with other bacteria than H. pyloribetween culture and histology may be because very few bacteria (less than 5 colonies) are cultured and the preparation of histological sections may remove much of the mucin and the contaminating bacteria. H. pyloriwas found alone without contamination in 60 biopsies by culture and in 83 biopsies by histology which indicate that H. pyloriis a true gastric microbiota (Figure 2).

No. of biopsiesCultureHistology
H. pyloriOther bacteriaH. pyloriOther bacteria
4111062498320

Table 1.

Comparison of culture and histological finding of H. pyloriand other bacteria (oral flora) in gastric biopsies.

Figure 2.

Imprint cytology showing the presence ofH. pylori(Giemsa stain, ×400) Rahbar [84].

All known mechanisms for H. pyloriresistance to all antibiotics are point mutations located on the chromosome (Table 2), indicating no uptake of plasmids or free DNA, which support that H. pyloriis the only bacteria in the true gastric microbiota and everything else is transient contaminating flora [13].

Resistance toMutation
AmoxicillinPBP1
ClarithromycinInfB
rp1V
A2142C
A2142G
A2143G
MetronidazolerdxA
frxA
fdxB
FluoroquinolonesgyrA
gyrB
TetracyclineAGA925-967TTC
RifampicinRNA polymerase subunit beta/beta

Table 2.

Examples of mutations in H. pyloricausing resistance to antibiotics.

Advertisement

3. Diagnosis of H. pylori

The detection of H. pylorican be done by invasive and noninvasive methods. The invasive methods require a biopsy, whereas the noninvasive methods are gentler for the patient.

Culture of H. pylorimay be difficult and the sensitivity may be rather low (50–85%) [14]. The sensitivity of the culture depends on transport time to the lab and the culture method used [15]. Different agar plates or incubation time can also give different results on the same biopsy. Two biopsies from the antrum and two biopsies from the fundus are preferred when making a culture as H. pyloriis unevenly distributed in the stomach. Culture is the only method by which it is possible to make a full susceptibility test.

Histology is an invasive method which requires a least one antral biopsy and preferably two antral and two corpus biopsies. The biopsy is stained with hematoxylin and eosin, Giemsa, or silver staining. H. pyloriis identified by the color, shape, and close relation to the mucosa and can be confirmed by immunohistochemistry using H. pylori–specific antibodies. The histology has shown to have a sensitivity at the same level as culture but is influenced by the size of the biopsy [14]. The number of biopsies and the location in the stomach also modify the sensitivity. The specificity of histology is lower than the specificity of the culture as histology cannot distinguish H. pylorifrom non–pylori Helicobacterspecies. The detection rates in cultures and histology varies with varying expertise of examiners. If the patient is taking proton pump inhibitor (PPI), bismuth, or antibiotics prior to gastroscopy, it might change the shape of H. pylorifrom curved rod to a coccoid form. This form is undetectable in the routine microscopy technique and requires fluorescent in situhybridization, immunohistochemistry with specific antibodies to H. pylori,or confirmation by the 16s rRNA and 23rRAN sequencing, which are irrespective of the shape of the bacteria [16].

H. pyloriurease breaks down urea to ammonia and carbon dioxide. This feature is used in the diagnostic methods “rapid urease test” (RUT) and “urea breath test” (UBT). RUT is an invasive method that preferably needs two biopsies. If the biopsy contains H. pylori,the release of ammonia increases the pH of the test medium, which is seen by a color change due to a pH indicator. The result of the test is fast and takes approximately ½ hour. UBT is a noninvasive method where the patient ingests 13C-labeled urea. If the patient is infected with H. pylori,orally ingested 13C-urea is broken down to 13C-labeled carbon dioxide, which is then exhaled. The sensitivity of the two tests is 75–85% for RUT and >95% for UBT. Likewise, the UBT has a higher specificity (<95%) when compared to RUT (85–95%). For both RUT and UBT, PPI and antibiotics can give false negative results. Furthermore, coccoid forms of H. pyloriwould not produce urease and would therefore give a false negative result [17].

Stool antigen test is another noninvasive method. It was first successfully described in 1997 using polyclonal antibodies [18]. Today monoclonal antibodies are used, and the sensitivity and the specificity are at the same levels as for UBT, but are preferred in special patients like children and patients with bleeding ulcers. This test can be done within ½ hour and is good for screening a patient for an infection with H. pylori. Despite this, antigen excretion may vary over time, and antigens may degrade while passing through the intestines, which may lead to false negative results.

The humoral antibody response to H. pylorican be measured by either serum IgG antibodies to H. pylori, which shows an ongoing or a previous infection, or by serum IgM antibodies, which shows an ongoing acute infection. H. pyloriIgG antibodies can be detected in sputum or urine but have a much lover sensitivity and specificity than serum antibodies. Antibodies to H. pyloriin serum can be tested by ELISA or “near patient test (NPT).” NPT uses immune-chromatography or passive agglutination. A 2013 study compared the NPT and the ELISA test. The study showed that the NPT never reach 90% in sensitivity, and the frequency of false negatives and false positives were high [19]. Several tested ELISA kits showed a high specificity and sensitivity above 90%. However, the serological kits may differ considerably depending on the antigens that are included in the kit as antibodies to low-molecular-weight antigens (outer membrane antigens) decline significantly within 3 months, whereas antibodies to high-molecular-weight antigens (CagA, VacA, etc.) may stay potent for years [20]. CagA antibodies remain stable for a long period of time and can probably be useful for the detection of H. pyloriinfections in patients with gastric cancer when other tests are negative [21]. Due to local strain distribution of H. pylori,the serology kits should be made by using local H. pyloristrains, and the kits should be locally validated [21].

Gastrin and pepsinogen are compounds produced in the stomach that depend on the changes in the gastric mucosa, and the serum levels of pepsinogens are a marker of atrophic gastritis [22]. This can be combined with the H. pyloriantibody test to predict the risk of developing gastric cancer.

Molecular methods have been of increasing interest in the field of microbiology and for detection of H. pylori. Polymerase chain reaction (PCR) seems to be more sensitive than any other method to detect H. pylori[23]. The main problem is that the method does not distinguish between live bacteria and DNA from dead bacteria. Real-time PCR (RT-PCR), which is a fast and quantitative PCR, seems to be more sensitive than classical PCR [24]. By sequencing the 16S RNA or 23S RNA region, it is possible to detect Helicobacterspecies and susceptibility to clarithromycin and tetracycline [25, 26, 27]. However, it is a more expensive and time-consuming method. A commercial kit has combined detection of H. pyloriand susceptibility to clarithromycin in a classical PCR. However, culture is still needed for a full susceptibility testing. There are so many point mutations causing resistance to antibiotics in H. pylorithat a full susceptibility analysis can only be detected by whole genome sequencing [28].

Advertisement

4. H. pylorisusceptibility to antibiotics

During the last decade, an increased number of H. pylorihave become resistant to antibiotics, especially to clarithromycin and levofloxacin [29]. The resistance rates to metronidazole have always been more than 15% worldwide, but the increasing resistance rates to clarithromycin and levofloxacin in some areas have become higher than 10–15%. Thus, these antibiotics are not recommended for first-line therapy of H. pyloriwithout prior susceptibility testing [21]. It is common to treat H. pyloriinfections without prior susceptibility testing, and different studies show a much lower resistance rate to clarithromycin in H. pylorifrom untreated patients than in H. pylorifrom previously treated patients [30, 31, 32]. It is therefore of the greatest importance to make susceptibility testing after the first treatment failure.

The susceptibility testing of H. pylorican be done by various methods. The most common are dilution methods, disk diffusion, and E-test.

The dilution method is regarded to be the golden standard for susceptibility testing. A two-fold dilution row of the test antibiotic is made. A standard number of bacteria (McFarland 3) are added to each tube with antibiotics. The bacterial growth is inhibited by high concentrations of antibiotics. The first tube with bacterial growth is called the minimal inhibitory concentration (MIC). H. pylorishould be grown for 48–72 hours under microaerobic conditions. It may be difficult to find a suitable media in which H. pylorigrows fast enough, and the slightest contamination will grow faster than H. pyloriand thereby spoil the susceptibility testing.

The disk diffusion test requires a small tablet of an antibiotic. The tablet is placed on the agar plate and is incubated for 3 days. After 3 days, there will be a zone around the tablet with no growth of H. pylori. This is the inhibition zone, and the diameter of the zone can be translated to an MIC value, which shows whether or not the bacteria are resistant to the antibiotic. To make the susceptibility testing of H. pylori, a McFarland 3.0 dilution of H. pyloriand Mueller-Hinton agar plates with 10% blood or chocolate ager plates should be used and incubated in microaerobic conditions at 37°C.

The E-test is a stripe with a concentration gradient of an antibiotic. The stripe is placed on the agar plate and is incubated for 3 days. After 3 days, there will be a droplet shape around the stripe with no growth of H. pylori(Figure 3). That concentration where H. pylorigrows close to stripe is the MIC value [33].

Figure 3.

Reading guide for E tests. (A) Colonies of a metronidazole-resistant subpopulation in the ellipse minimum inhibitory concentration (MIC) >32; (B) trailing of microcolonies at the end point MIC 0.5 μg/ml. Warburton-Timms and McNulty [85].

Advertisement

5. Treatment of H. pyloriinfection

H. pyloriinfections are usually treated with a combination of antibiotics and nonantibiotics (proton pump inhibitor [PPI] or bismuth salts). Usually, a combination of two or three antibiotics is used, as the effect of monotherapy has been found insufficient. The most commonly used antibiotics are amoxicillin, clarithromycin, metronidazole, fluoroquinolones, tetracycline, and rifampicin (Table 3).

GroupPreparation
AntibioticsAmoxicillin
Clarithromycin
Metronidazole
Tetracycline
Levofloxacin
Ciprofloxacin
Rifampicin
NonantibioticsPPI
Bismuth nitrate
Bismuth citrate
Bismuth subsalicylate
H2 blocker

Table 3.

Commonly used antibiotics and nonantibiotics for treatment of H. pyloriinfections.

H. pyloriis found in very different environments such as the gastric lumen with a relatively low pH, in between the epithelial cells and on the basement membrane with a neutral pH but protected as intracellular microorganisms. When choosing antibiotics, it is important to select antibiotic to which H. pyloriis sensitive and is active in all the environmental niches where H. pylorioccurs. It is also important to look at the duration of the efficacy of antibiotics to keep stable levels above the minimal inhibitory concentrations.

PPI in standard doses do not have antibacterial effect on H. pylori, but 5–10 times higher doses have a direct effect on H. pylori. Bismuth salts binds to the surface of H. pyloribut have a relatively little antibacterial effect. However, bismuth salts affect the respiratory chain at the same points as metronidazole and thereby reverts metronidazole resistance in H. pyloriand thus becomes sensitive to metronidazole.

Advertisement

6. Prevalence of H. pyloriresistance to antibiotics

When analyzing different studies around the world, the primary resistance rate for H. pylorivaries. The highest rate of primary metronidazole (MTZ) resistance is found in Africa (52%) followed by South America (49%) and Asia (43%). The lowest resistance rate is found in Europe (35%). The highest primary resistance rates for clarithromycin and levofloxacin are found in South America (20 and 27%) while the lowest rates are found in Europe (12 and 10%) [30, 31, 32, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67]. There is a significantly (p < 0.001) higher risk of primary metronidazole and levofloxacin resistance in Asian when compared to Europe.

The high rate of metronidazole resistance seen in developing countries may be due to the high use of metronidazole for treatment of parasites and gynecological infections [62, 68]. It is therefore likely that the patients who are treated for H. pyloriwith metronidazole for the first time are resistant for this treatment. It is recommended to use bismuth therapy together with metronidazole in the first-line treatment in areas with high metronidazole resistance [21].

The high resistance rates for clarithromycin and levofloxacin in South America, Africa, and Asia can be due to the use of huge amounts of antibiotics in general [69]. Typically, the diagnostics are not precise, and the patients are treated with more a broad spectrum of antibiotics for a longer period. This can lead to a faster development of resistance in H. pylori[70].

A large multinational study tested H. pyloriresistance in 18 European countries [29]. All 18 countries used E-test for the susceptibility testing and only tested patients who had never been treated for H. pyloribefore. In total, 2204 people were included in the study, and the resistance rate for adults were 18% for clarithromycin, 14% for levofloxacin, and 35% for metronidazole. They found a significant association between the use of only long-acting macrolides and clarithromycin resistance. The levofloxacin resistance was significantly associated with the use of quinolone.

The prevalence of H. pyloriresistance to antibiotics was tested in Denmark in 1997, 1998–2004, and 2013 [71, 72, 73]. Throughout the years, the resistance for clarithromycin has increased from 0% in 1997 to 53% in 2013, and likewise, the resistance for metronidazole increased from 20 to 74% [12, 13, 14]. None of the studies mention whether or not the patients have had H. pylorieradication therapy prior to testing or not, which might explain the huge increase in resistance.

6.1. Effect of antibiotic treatment on H. pyloriresistance rates

International guidelines recommend first line of treatment of H. pyloriinfections with 10 days of triple therapy (PPI, clarithromycin, and metronidazole or amoxicillin). If this fails, a treatment with four types of medicine (PPI, bismuth subsalicylate, tetracycline, and metronidazole) for 2 weeks is recommended. After treatment failure for the second time, it is recommended to perform a gastroscopy and susceptibility testing for H. pylori[21].

The primary and secondary resistance rate for H. pylorihas only been described in eight studies [30, 32, 40, 43, 58, 65, 66, 74]. By using “Review Manager 5.3,” it is possible to compare the studies via Forest plots. The meta-analyses show that the secondary resistance is significantly higher (p < 0.001) than the primary.

The meta-analysis shows a high increasing resistance rate for all three antibiotics when the patient had been treated for H. pyloripreviously. The high and increasing resistance rates to metronidazole, clarithromycin, and levofloxacin make it uncertain that these antibiotics should be recommended as the first-line therapy of H. pyloriinfections without prior endoscopy and susceptibility testing (Figure 4A–C).

Figure 4.

Meta-analysis for MTZ (A), CLR (B), and LEV (C). For all three antibiotics, there is a higher odds ratio for resistance if the patient is previously treated for infection withH. pylori.

6.2. Vaccine

Another way to overcome H. pyloriinfections is with a vaccine. In the past couple of years, many studies have investigated developing an effective and safe vaccine. The development of an effective vaccine is complicated by the noninvasive nature of H. pylori.It stays in the lumen of the stomach and does not cross the epithelium. Therefore, the vaccine should affect T helper memory cells, which are required to stay in the lumen during a H. pyloriinfection [75].

Appropriate bacterial antigens, safe and effective adjuvants, and a route of delivery are required for developing a vaccine. For the bacterial antigen, most studies use urease, but other antigens are investigated for example Cag L. The CagL is a protein essential for the pathogenesis of H. pylori. It binds to integrins in the mucosa and triggers the release of the carcinogen CagA to the host cells through the type IV secretin system. CagL also introduces an IL-8 response, which causes inflammation [76]. The use of CagL in a subunit vaccine was investigated by Choudhari et al. in 2013 [75]. The study showed that CagL was stable in pH 4–6 and that sucrose enhances the stability.

The use of heat shock proteins in a vaccine introduced protective immunity without requiring the addition of an adjuvant. The protection, however, is not optimal because sterilizing immunity is not obtained, which is shown in a study from 2014 [77].

A derivate of the cholera toxin (CTA1-DD) and safe nontoxic mutants of Escherichia coliheat labile toxin (dm2T) have also been tested as potential adjuvants. CTA1-DD enhances the Th1 and Th17 immunity and reduces the bacterial colonization by three- to eight-fold [78]. The use of dm2T was equally as effective as the gold standard H. pylorivaccine containing cholera toxin [79].

The routes of delivery that have been tested are sublingual, intranasal, respiratory, and oral [79]. A study on humans from China (2015) tested a vaccine based on a urease B subunit and heat-labile enterotoxin B subunit (gene derived from E. coliH44815) [80]. The vaccine was taken orally three times (day 0, 14, and 28). This study showed a vaccine efficacy of 71.8% in the first year, 55% in in the second year, and 55.8% in the third year after vaccinations. Even though these findings are excellent, a 100% effective vaccine is still not developed. More studies and longer time follow-ups are needed before a fully effective vaccine is on the market. If a fully effective vaccine is made, it would be the best heath measure against H. pyloriinfections and gastric cancer.

Advertisement

7. Discussion

The human gastric microbiota may be difficult to estimate since samples for microbiome investigations often are contaminated with oral bacterial flora during gastroscopy. And the studies in these fields do not make any attempt to remove the oral contamination prior to sequencing. Histological examination of biopsies reveals H. pylorias the only bacteria in close relation to the epithelial cells in the gastric mucosa. When H. pyloriis seen in stomach samples, there is always a strong humoral and cellular immune response to H. pyloriand it thereby fulfills the criteria for a true infection but also a colonization. This has not been shown for any other bacteria.

Thus, in noncancer patients, H. pyloriseems to be the gastric microbiota. In patients with gastric cancer, there may be a different situation as the mucosa is disintegrated and an overgrowth of intestinal bacteria is common. However, it remains to be shown that the intestinal bacteria adhere to the gastric mucosa and cause a local immune response. It is, therefore, believed that H. pyloriis still the most important gastric pathogen.

An increasing resistance to antibiotics in H. pylorihas been seen worldwide especially to metronidazole, clarithromycin, and levofloxacin. This is a worrying development as it may interfere with our recommendations for primary treatment of H. pyloriwithout susceptibility testing. It is a question how fast the resistance occurs. Should susceptibility testing be done after first treatment failure or can it wait until the second treatment failure as recommended? At least the resistance rates are much higher in previously treated patients than in untreated patients.

Due to the high resistant rates, it is necessary to perform a susceptibility test before starting the treatment. The advantages would be a better and maybe quicker eradication of the H. pyloriinfection. Disadvantages of early susceptibility testing are the cost and time of the analyses. Biopsies are an invasive method and may often be painful for the patient. Furthermore, it takes up to 14 days before a full susceptibility test is completed, so the real treatment starts approximately 2 weeks after the doctor confirms the presence of H. pylori. By this time, the patient could have been done with the first line of treatment. In the short perspective, a quick susceptibility test would be very time consuming, but in the long perspective, it might save the patient from several treatments and prevent the relapse of the H. pyloriinfection. But it also gives a better overview on how quickly H. pyloridevelops resistance to the recommended treatment.

When detecting H. pylori,the best would be a quick a method that was as quick as PCR but also made it possible to have a full susceptibility test incorporated. New primers for detecting antibiotic resistance are in progress, but the problem is that there are many different mutations leading to the same resistance profile. H. pylorionly develops antibiotic resistance by mutation in the genome. For MTZ, mutations in at least nine different genes are known to contribute to MTZ resistance [13]. If the detecting of MTZ resistance should be made by PCR, it would be necessary to perform the PCR with many different primers all looking for one specific mutation. In theory, this would be the most sensitive way to find MTZ resistance, but in practice, it would be almost impossible, take a lot of time, and would be expensive.

Due to the enormous amount of mutations leading to antibiotic resistant, the culture and susceptibility testing done by E-test is still the best and most economical way.

The increasing resistant rates to the most commonly used antibiotics raises the question of whether other antibiotics or combinations of antibiotic and nonantibiotic should be used for primary treatment of H. pyloriinfections without susceptibility testing. Bismuth compounds in standard doses, proton pump inhibitors, and acid suppressing compounds in high doses may convert the MTZ resistance [81]. This makes MTZ useful in combination with these compounds, especially the bismuth compounds, which have been shown in clinical studies [21]. Nonantibiotics such as neuroleptics and other compounds acting on the central nerves system have anti–H. pylorieffect in vitro[82] and compounds without effect on the central nervous system may be candidates for alternative treatment. Herbs like broccoli and green tee have some effect on H. pyloriand may in combination with antibiotics and nonantibiotics be candidates for treatment in the future [83].

Advertisement

8. Conclusion

H. pyloriis the most important gastric pathogen and may constitute the true gastric microbiota. It is, therefore, important to follow the development of resistance in H. pylorito antibiotics. With the increased resistance of H. pylorito metronidazole, clarithromycin, and levofloxacin, it may be doubtful if these antibiotics can be recommended as primary treatment without susceptibility testing.

Advertisement

Conflict of interest

The authors declare no conflicts of interests.

References

  1. 1. Ursell LK, Metcalf JL, Parfrey LW, et al. Defining the human microbiome. Nutrition Reviews. 2012;70(Suppl 1):S38-S44
  2. 2. Jackson MA, Bonder MJ, Kuncheva Z, et al. Detection of stable community structures within gut microbiota co-occurrence networks from different human populations. PeerJ. 2018;6
  3. 3. Jorgensen JH, Pfaller MA, Karen C, et al. Manual of Clinical Microbiology. 11th ed. Washington DC: ASM Press; 2015
  4. 4. Aviles-Jimenez F, Vazquez-Jimenez F, Medrano-Guzman R, et al. Stomach microbiota composition varies between patients with non-atrophic gastritis and patients with intestinal type of gastric cancer. Scientific Reports. 2015;4(1):4202
  5. 5. Wang L, Zhou J, Xin Y, Geng C, et al. Bacterial overgrowth and diversification of microbiota in gastric cancer. European Journal of Gastroenterology & Hepatology. 2016;28(3):261-266
  6. 6. Bik EM, Eckburg PB, Gill SR, et al. Molecular analysis of the bacterial microbiota in the human stomach. Proceedings of the National Academy of Sciences. 2006;103(3):732-737
  7. 7. Maldonado-Contreras A, Goldfarb KC, Godoy-Vitorino F, et al. Structure of the human gastric bacterial community in relation toHelicobacter pyloristatus. The ISME Journal. 2011;5(4):574-579
  8. 8. Yang I, Nell S, Suerbaum S. Survival in hostile territory: the microbiota of the stomach. FEMS Microbiology Reviews. 2013;37(5):736-761
  9. 9. Liu X, Nie W, Liang J, et al. Interaction ofHelicobacter Pyloriwith other microbiota species in the development of gastric cancer. Archives of Clinical Microbiology. 2017;8(2)
  10. 10. Carroll AC, Wong A. Plasmid persistence: Costs, benefits and the plasmid paradox. Canadian Journal of Microbiology. May 2018;64(5):293-304. cjm-2017-0609
  11. 11. Dorward DW, Garon CF. DNA-binding proteins in cells and membrane blebs ofNeisseria gonorrhoeae. Journal of Bacteriology. 1989;171(8):4196-4201
  12. 12. Durão P, Balbontín R, Gordo I. Evolutionary mechanisms shaping the maintenance of antibiotic resistance. Trends in Microbiology. Aug 2018;26(8):677-691
  13. 13. Arslan N, Yılmaz Ö, Demiray-Gürbüz E. Importance of antimicrobial susceptibility testing for the management of eradication inHelicobacter pyloriinfection. World Journal of Gastroenterology. 2017;23(16):2854
  14. 14. Bytzer P, Dahlerup JF, Eriksen JR, et al. Diagnosis and treatment ofHelicobacter pylori infection. Danish Medical Bulletin. 2011;58(4):1-5
  15. 15. Cuchi E, Forné M, Quintana S. Comparison of two transport media and three culture media for primary isolation ofHelicobacter pylorifrom gastric biopsies. European Society of Clinical Microbiology and Infectious Diseases. 2002;8:609-610
  16. 16. Patel SK, Pratap CB, Jain AK, et al. Diagnosis ofHelicobacter pylori:What should be the gold standard? World Journal of Gastroenterology. 2014;20(36):12847-12859
  17. 17. Koletzko S. Noninvasive diagnostic tests forHelicobacter pyloriinfection in children. Canadian Journal of Gastroenterology. 2005;19(7):433-439
  18. 18. Makristathis A, Pasching E, Schütze K, et al. Detection ofHelicobacter pyloriin stool specimens by PCR and antigen enzyme immunoassay. Journal of Clinical Microbiology. 1998;36(9):2772-2774
  19. 19. Burucoa C, Delchier JC, Courillon-Mallet A, et al. Comparative evaluation of 29 commercialHelicobacter pyloriserological kits. Helicobacter. 2013;18(3):169-179
  20. 20. Andersen LP, Espersen F, Souckova A, et al. Isolation and preliminary evaluation of a low-molecular-mass antigen preparation for improved detection ofHelicobacter pyloriimmunoglobulin G antibodies. Clinical and Diagnostic Laboratory Immunology. 1995;2(2):156-159
  21. 21. Malfertheiner P, Megraud F, O’morain CA, et al. Management ofHelicobacter pyloriinfection—the Maastricht V/florence consensus report. Gut. 2017;66:6-30
  22. 22. Shimoyama T, Oyama T, Matsuzaka M, et al. Comparison of a stool antigen test and serology for the diagnosis ofHelicobacter pyloriinfection in mass survey. Helicobacter. 2009;14(2):87-90
  23. 23. Cosgun Y, Yildirim A, Yucel M, et al. Evaluation of invasive and noninvasive methods for the diagnosis ofHelicobacter Pyloriinfection. Asian Pacific Journal of Cancer Prevention. 2016;17(12):5265-5272
  24. 24. Monno R, Giorgio F, Carmine P, et al.Helicobacter pyloriclarithromycin resistance detected by Etest and TaqMan real-time polymerase chain reaction: A comparative study. APMIS. 2012;120(9):712-717
  25. 25. Redondo JJ, Keller PM, Zbinden R, et al. A novel RT-PCR for the detection ofHelicobacter pyloriand identification of clarithromycin resistance mediated by mutations in the 23S rRNA gene. Diagnostic Microbiology and Infectious Disease. 2018;90(1):1-6
  26. 26. Dadashzadeh K, Milani M, Rahmati M, et al. Real-time PCR detection of 16S rRNA novel mutations associated withHelicobacter pyloritetracycline resistance in Iran. Asian Pacific Journal of Cancer Prevention. 2014;15(20):8883-8886
  27. 27. Pastukh N, Binyamin D, On A, et al. GenoType® HelicoDR test in comparison with histology and culture forHelicobacter pyloridetection and identification of resistance mutations to clarithromycin and fluoroquinolones. Helicobacter. 2017;22(6):e12447
  28. 28. Draper JL, Hansen LM, Bernick DL, et al. Fallacy of the unique genome: Sequence diversity within singleHelicobacter pyloristrains. Fraser CM, editor. MBio. 2017;8(1):e02321-e02316
  29. 29. Megraud F, Coenen S, Versporten A, et al.Helicobacter pyloriresistance to antibiotics in Europe and its relationship to antibiotic consumption. Gut. 2013;62(1):34-42
  30. 30. Gao W, Cheng H, Hu F, et al. The evolution ofHelicobacter pyloriantibiotics resistance over 10 years in Beijing, China. Helicobacter. 2010;15:460-466
  31. 31. Selgrad M, Meile J, Bornschein J, et al. Antibiotic susceptibility ofHelicobacter pyloriin central Germany and its relationship with the number of eradication therapies. European Journal of Gastroenterology & Hepatology. 2013;25(11):1257-1260
  32. 32. Almeida N, Romãozinho JM, Donato MM, et al.Helicobacter pyloriantimicrobial resistance rates in the central region of Portugal. Clinical Microbiology and Infection. 2014;20(11):1127-1133
  33. 33. Ogata SK, Gales AC, Kawakami E. Antimicrobial susceptibility testing forHelicobacter pyloriisolates from Brazilian children and adolescents: Comparing agar dilution, e-test, and disk diffusion. Brazilian Journal of Microbiology. 2014;45(4):1439-1448
  34. 34. Ahmad N, Zakaria WR, Mohamed R. Analysis of antibiotic susceptibility patterns ofHelicobacter pyloriisolates from Malaysia. Helicobacter. 2011;16:47-51
  35. 35. Ang TL, Fock KM, Ang D, et al. The changing profile ofHelicobacter pyloriantibiotic resistance in Singapore: A 15-year study. Helicobacter. 2016;21(4):261-265
  36. 36. Binh TT, Shiota S, Nguyen LT, et al. The incidence of primary antibiotic resistance ofHelicobacter pyloriin Vietnam. Nixon AE, editor. Journal of Clinical Gastroenterology. 2013;47(3):233-238
  37. 37. Boehnke KF, Valdivieso M, Bussalleu A, et al. Antibiotic resistance amongHelicobacter pyloriclinical isolates in Lima, Peru. Infection and Drug Resistance. 2017;10:85-90
  38. 38. Bouihat N, Burucoa C, Benkirane A, et al.Helicobacter pyloriprimary antibiotic resistance in 2015 in Morocco: A phenotypic and genotypic prospective and multicenter study. Microbial Drug Resistance. 2016;23(6):727-732
  39. 39. Caliskan R, Tokman HB, Erzin Y, et al. Antimicrobial resistance ofHelicobacter pyloristrains to five antibiotics, including levofloxacin, in Northwestern Turkey. Revista da Sociedade Brasileira de Medicina Tropical. 2015;48(3):278-284
  40. 40. Chang WL, Sheu BS, Cheng HC, et al. Resistance to metronidazole, clarithromycin and levofloxacin ofHelicobacter pyloribefore and after clarithromycin-based therapy in Taiwan. Journal of Gastroenterology and Hepatology. 2009;24(7):1230-1235
  41. 41. Cheng A, Sheng WH, Liou JM, et al. Comparative in vitro antimicrobial susceptibility and synergistic activity of antimicrobial combinations againstHelicobacter pyloriisolates in Taiwan. Journal of Microbiology, Immunology, and Infection. 2015;48(1):72-79
  42. 42. Cuadrado-Lavín A, Salcines-Caviedes JR, Carrascosa MF, et al. Antimicrobial susceptibility ofHelicobacter pylorito six antibiotics currently used in Spain. The Journal of Antimicrobial Chemotherapy. 2012;67(1):170-173
  43. 43. Ducournau A, Bénéjat L, Sifré E, et al.Helicobacter pyloriresistance to antibiotics in 2014 in France detected by phenotypic and genotypic methods. Clinical Microbiology and Infection. 2016;22(8):715-718
  44. 44. Eisig JN, Silva F, Barbuti RC, et al.Helicobacter pyloriantibiotic resistance in Brazil: Clarithromycin is still a good option. Arquivos de Gastroenterologia. 2011;48(4):261-264
  45. 45. Farshad S, Alborzi A, Japoni A, et al. Antimicrobial susceptibility ofHelicobacter pyloristrains isolated from patients in Shiraz, Southern Iran. World Journal of Gastroenterology. 2010;16(45):5746-5751
  46. 46. Dargiene G, Kupcinskas J, Jonaitis L, et al. Primary antibiotic resistance ofHelicobacter pyloristrains among adults and children in a tertiary referral centre in Lithuania. APMIS. 2017
  47. 47. Goh KL, Navaratnam P. HighHelicobacter pyloriresistance to metronidazole but zero or low resistance to clarithromycin, levofloxacin, and other antibiotics in Malaysia. Helicobacter. 2011;16(3):241-245
  48. 48. Gościniak G, Biernat M, Grabińska J, et al. The antimicrobial susceptibility ofHelicobacter pyloristrains isolated from children and adults with primary infection in the Lower Silesia Region, Poland. Polish Journal of Microbiology. 2014;63(1):57-61
  49. 49. Gunnarsdottir AI, Gudjonsson H, Hardardottir H, et al. Antibiotic susceptibility ofHelicobacter pyloriin Iceland. Infectious Diseases. (Auckland). 2017;49(9):647-654
  50. 50. Karczewska E, Wojtas-Bonior I, Sito E, et al. A primary and secondary clarithromycin, metronidazole, amoxicillin and levofloxacin resistance toHelicobacter pyloriin southern Poland. Pharmacological Reports. 2011;63(3):799-807
  51. 51. Kostamo P, Veijola L, Oksanen A, et al. Recent trends in primary antimicrobial resistance ofHelicobacter pyloriin Finland. International Journal of Antimicrobial Agents. 2011;37(1):22-25
  52. 52. Kupcinskas L, Rasmussen L, Jonaitis L, et al. Evolution ofHelicobacter pylorisusceptibility to antibiotics during a 10-year period in Lithuania. APMIS. 2013;121(5):431-436
  53. 53. Larsen AL, Ragnhildstveit E, Moayeri B, et al. Resistance rates of metronidazole and other antibacterials inHelicobacter pylorifrom previously untreated patients in Norway. APMIS. 2013;121(4):353-358
  54. 54. Ben Mansour K, Burucoa C, Zribi M, et al. Primary resistance to clarithromycin, metronidazole and amoxicillin ofHelicobacter pyloriisolated from Tunisian patients with peptic ulcers and gastritis: a prospective multicentre study. Annals of Clinical Microbiology and Antimicrobials. 2010;9(1):22
  55. 55. Miftahussurur M, Syam AF, Nusi IA, et al. Surveillance ofHelicobacter pyloriantibiotic susceptibility in Indonesia: Different resistance types among regions and with novel genetic mutations. PLoS One. 2016;11(12):1-17
  56. 56. O’Connor A, Taneike I, Nami A, et al.Helicobacter pyloriresistance rates for levofloxacin, tetracycline and rifabutin among Irish isolates at a reference centre. Irish Journal of Medical Science. 2013:1-3
  57. 57. Quek C, Pham ST, Tran KT, et al. Antimicrobial susceptibility and clarithromycin resistance patterns ofHelicobacter pyloriclinical isolates in Vietnam. F1000Research. 2016;5(0):671
  58. 58. Raymond J, Lamarque D, Kalach N, et al. High level of antimicrobial resistance in FrenchHelicobacter pyloriisolates. Helicobacter. 2010;15(1):21-27
  59. 59. Saracino IM, Zullo A, Holton J, et al. High prevalence of primary antibiotic resistance inHelicobacter pyloriisolates in Italy. Journal of Gastrointestinal and Liver Diseases. 2012;21(4):363-365
  60. 60. Seck A, Burucoa C, Dia D, et al. Primary antibiotic resistance and associated mechanisms inHelicobacter pyloriisolates from Senegalese patients. Annals of Clinical Microbiology and Antimicrobials. 2013;12:3
  61. 61. Shiota S, Reddy R, Alsarraj A, et al. Antibiotic resistance ofHelicobacter pyloriamong male United States veterans. Clinical Gastroenterology and Hepatology. 2015;13(9):1616-1624
  62. 62. Teh X, Khosravi Y, Lee WC, et al. Functional and molecular surveillance ofHelicobacter pyloriantibiotic resistance in Kuala Lumpur. PLoS One. 2014;9(7)
  63. 63. Torres-Debat ME, Pérez-Pérez G, Olivares A, et al. Antimicrobial susceptibility ofHelicobacter pyloriand mechanisms of clarithromycin resistance in strains isolated from patients in Uruguay. Revista Española de Enfermedades Digestivas. 2009;101(11):757-762
  64. 64. Korn VR, Gumnarai P, Ratanachu-ek T, et al. Nationwide survey ofHelicobacter pyloriantibiotic resistance in Thailand. Diagnostic Microbiology and Infectious Disease. 2013;77(4):346-349
  65. 65. Wuppenhorst N, Draeger S, Stuger HP, et al. Prospective multicentre study on antimicrobial resistance ofHelicobacter pyloriin Germany. The Journal of Antimicrobial Chemotherapy. 2014;69(11):3127-3133
  66. 66. Zollner-Schwetz I, Leitner E, Plieschnegger W, et al. Primary resistance ofHelicobacter pyloriis still low in Southern Austria. International Journal of Medical Microbiology. 2016;306(4):206-211
  67. 67. Wu IT, Chuah SK, Lee CH, et al. Five-year sequential changes in secondary antibiotic resistance ofHelicobacter pyloriin Taiwan. World Journal of Gastroenterology. 2015;21(37):10669-10674
  68. 68. Oleastro M, Cabral J, Ramalho PM, et al. Primary antibiotic resistance ofHelicobacter pyloristrains isolated from Portuguese children: A prospective multicentre study over a 10 year period. The Journal of Antimicrobial Chemotherapy. 2011;66(10):2308-2311
  69. 69. Van Boeckel TP, Gandra S, Ashok A, et al. Global antibiotic consumption 2000 to 2010: An analysis of national pharmaceutical sales data. The Lancet Infectious Diseases. 2014;14(8):742-750
  70. 70. WHO. Antimicrobial Resistance. Global Report on Surveillance. Geneva: World Health Organization; 2014. pp. 383-394
  71. 71. Hartzen SH, Andersen LP, Bremmelgaard A, et al. Antimicrobial susceptibility testing of 230Helicobacter pyloristrains: Importance of medium, inoculum, and incubation time. Antimicrobial Agents and Chemotherapy. 1997;41(12):2634-2349
  72. 72. Rasmussen L.Helicobacter pylori[PhD thesis]. Copenhagen; 2013
  73. 73. Petersen AM, Gjøde P, Vinge OD, et al.Helicobacter pyloriantimicrobial resistance and risk factors in Denmark 1998-2004: No need for concern? Helicobacter. 2006;11(3):210-211
  74. 74. Selgrad M, Tammer I, Langner C, et al. Different antibiotic susceptibility between antrum and corpus of the stomach, a possible reason for treatment failure ofHelicobacter pyloriinfection. World Journal of Gastroenterology. 2014;20(43):16245-16251
  75. 75. Choudhari SP, Pendleton KP, Ramsey JD, et al. A systematic approach toward stabilization of CagL, a protein antigen fromHelicobacter Pylorithat is a candidate subunit vaccine. Journal of Pharmaceutical Sciences. 2013;102:2508-2519
  76. 76. Kwok T, Zabler D, Urman S, et al.Helicobacterexploits integrin for type IV secretion and kinase activation. Nature. 2007;449(7164):862-866
  77. 77. Chionh YT, Arulmuruganar A, Venditti E, et al. Heat shock protein complex vaccination induces protection againstHelicobacter pyloriwithout exogenous adjuvant. Vaccine. 2014;32:2350-2358
  78. 78. Nedrud JG, Bagheri N, Schön K, et al. Subcomponent vaccine based on CTA1-DD adjuvant with incorporated UreB class II peptides stimulates protectiveHelicobacter pyloriimmunity. Ho PL, editor. PLoS One. 2013;8(12):e83321
  79. 79. D’Elios MM, Czinn SJ. Immunity, Inflammation, and Vaccines forHelicobacter pylori. Helicobacter. 2014;19(S1):19-261
  80. 80. Zeng M, Mao XH, Li JX, et al. Efficacy, safety, and immunogenicity of an oral recombinantHelicobacter pylorivaccine in children in China: A randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. 2015;386(10002):1457-1464
  81. 81. Chen M, Jensen B, Zhai L, et al. Nizatidine and omeprazole enhance the effect of metronidazole onHelicobacter pyloriin vitro. International Journal of Antimicrobial Agents. 2002;19(3):195-200
  82. 82. Kristiansen JE, Justesen T, Hvidberg EF, et al. Trimipramine and other antipsychotics inhibitCampylobacter pyloriin vitro. Pharmacology & Toxicology. 1989;64(4):386-388
  83. 83. Fahey JW, Stephenson KK, Wallace AJ. Dietary amelioration ofHelicobacterinfection. Nutrition Research. 2015;35(6):461-473
  84. 84. Rahbar M, Mardanpur K, Tavafzadeh R. Imprint cytology: A simple, cost effectiveness analysis for diagnosingHelicobacter pylori, in west of Iran. Medical journal of the Islamic Republic of Iran. 2012;26(1):12-16
  85. 85. Warburton-Timms V, McNulty C. Role of screening agar plates for in vitro susceptibility testing ofHelicobacter pyloriin a routine laboratory setting. Journal of Clinical Pathology. 2001;54(5):408-411

Written By

Agnes Tving Stauning, Rie Louise Møller Nordestgaard, Tove Havnhøj Frandsen and Leif Percival Andersen

Submitted: March 9th, 2018 Reviewed: August 1st, 2018 Published: November 5th, 2018