H. pylori antibiotic resistance reaches ‘alarming levels’

The first-line treatment of individuals with Helicobacter pylori infection using clarithromycin-based triple therapies or, if penicillin allergic, bismuth-based quadruple therapies is generally effective. However, reports of declining therapeutic efficacy have led to published guidelines to recommend confirmation of H. pylori eradication after completing a course of antibiotics. It is believed that increasing antibiotic use in agriculture and medicine around the globe have contributed to the increasing H. pylori antibiotic resistance and declining efficacy of standard H. pylori regimens. 

Indeed, most H. pylori guidelines recommend antibiotic sensitivity testing after failing two courses of treatment; however, performing such testing successfully may require sending fresh gastric biopsy samples to an in-house H. pylori culture lab within 1 hour, which is generally not available to most clinicians. Clearly, the gap in knowledge of local antibiotic resistance could be addressed by having a readily accessible culture facility and the testing should be reimbursed by health insurance. 

Single-center experiences with antibiotic sensitivity–guided salvage therapy in the United States, however, registered a lower efficacy rate of approximately 50%, which indicates that other host factors (such as gastric acidity pH less than 5.5 or body mass index greater than 30 kg/m2) may affect the minimum inhibitory concentration (MIC) of the antibiotics against H. pylori. 

In order to better study the effects of these host factors relative to the effect of antibiotic resistance on therapeutic efficacy, it is critical that we practice precision medicine by determining the antibiotic sensitivity of the H. pylori strain prior to initiating the antibiotic treatment. It may be possible to achieve more than 90% therapeutic efficacy given known antibiotic sensitivities of the bacteria and optimized host factors to lower the MIC. In addition, with the increasing awareness of the importance of gut microbiota in health and disease, clinicians should strive to narrow the antibiotic coverage that will be possible if antibiotic sensitivity is known (for example, use high-dose amoxicillin and proton-pump inhibitor dual therapy). 

John Y. Kao, MD, AGAF, is the current chair of the AGA Institute Council Esophageal, Gastric and Duodenal Disorders Section, a physician investigator in the University of Michigan Center for Gastrointestinal Research, and an associate professor in the department of medicine in the division of gastroenterology & hepatology and an associate program director of the GI Fellowship Program at Michigan Medicine at the University of Michigan, Ann Arbor. He has no conflicts.

The first-line treatment of individuals with Helicobacter pylori infection using clarithromycin-based triple therapies or, if penicillin allergic, bismuth-based quadruple therapies is generally effective. However, reports of declining therapeutic efficacy have led to published guidelines to recommend confirmation of H. pylori eradication after completing a course of antibiotics. It is believed that increasing antibiotic use in agriculture and medicine around the globe have contributed to the increasing H. pylori antibiotic resistance and declining efficacy of standard H. pylori regimens. 

Indeed, most H. pylori guidelines recommend antibiotic sensitivity testing after failing two courses of treatment; however, performing such testing successfully may require sending fresh gastric biopsy samples to an in-house H. pylori culture lab within 1 hour, which is generally not available to most clinicians. Clearly, the gap in knowledge of local antibiotic resistance could be addressed by having a readily accessible culture facility and the testing should be reimbursed by health insurance. 

Single-center experiences with antibiotic sensitivity–guided salvage therapy in the United States, however, registered a lower efficacy rate of approximately 50%, which indicates that other host factors (such as gastric acidity pH less than 5.5 or body mass index greater than 30 kg/m2) may affect the minimum inhibitory concentration (MIC) of the antibiotics against H. pylori. 

In order to better study the effects of these host factors relative to the effect of antibiotic resistance on therapeutic efficacy, it is critical that we practice precision medicine by determining the antibiotic sensitivity of the H. pylori strain prior to initiating the antibiotic treatment. It may be possible to achieve more than 90% therapeutic efficacy given known antibiotic sensitivities of the bacteria and optimized host factors to lower the MIC. In addition, with the increasing awareness of the importance of gut microbiota in health and disease, clinicians should strive to narrow the antibiotic coverage that will be possible if antibiotic sensitivity is known (for example, use high-dose amoxicillin and proton-pump inhibitor dual therapy). 

John Y. Kao, MD, AGAF, is the current chair of the AGA Institute Council Esophageal, Gastric and Duodenal Disorders Section, a physician investigator in the University of Michigan Center for Gastrointestinal Research, and an associate professor in the department of medicine in the division of gastroenterology & hepatology and an associate program director of the GI Fellowship Program at Michigan Medicine at the University of Michigan, Ann Arbor. He has no conflicts.

The first-line treatment of individuals with Helicobacter pylori infection using clarithromycin-based triple therapies or, if penicillin allergic, bismuth-based quadruple therapies is generally effective. However, reports of declining therapeutic efficacy have led to published guidelines to recommend confirmation of H. pylori eradication after completing a course of antibiotics. It is believed that increasing antibiotic use in agriculture and medicine around the globe have contributed to the increasing H. pylori antibiotic resistance and declining efficacy of standard H. pylori regimens. 

Indeed, most H. pylori guidelines recommend antibiotic sensitivity testing after failing two courses of treatment; however, performing such testing successfully may require sending fresh gastric biopsy samples to an in-house H. pylori culture lab within 1 hour, which is generally not available to most clinicians. Clearly, the gap in knowledge of local antibiotic resistance could be addressed by having a readily accessible culture facility and the testing should be reimbursed by health insurance. 

Single-center experiences with antibiotic sensitivity–guided salvage therapy in the United States, however, registered a lower efficacy rate of approximately 50%, which indicates that other host factors (such as gastric acidity pH less than 5.5 or body mass index greater than 30 kg/m2) may affect the minimum inhibitory concentration (MIC) of the antibiotics against H. pylori. 

In order to better study the effects of these host factors relative to the effect of antibiotic resistance on therapeutic efficacy, it is critical that we practice precision medicine by determining the antibiotic sensitivity of the H. pylori strain prior to initiating the antibiotic treatment. It may be possible to achieve more than 90% therapeutic efficacy given known antibiotic sensitivities of the bacteria and optimized host factors to lower the MIC. In addition, with the increasing awareness of the importance of gut microbiota in health and disease, clinicians should strive to narrow the antibiotic coverage that will be possible if antibiotic sensitivity is known (for example, use high-dose amoxicillin and proton-pump inhibitor dual therapy). 

John Y. Kao, MD, AGAF, is the current chair of the AGA Institute Council Esophageal, Gastric and Duodenal Disorders Section, a physician investigator in the University of Michigan Center for Gastrointestinal Research, and an associate professor in the department of medicine in the division of gastroenterology & hepatology and an associate program director of the GI Fellowship Program at Michigan Medicine at the University of Michigan, Ann Arbor. He has no conflicts.