Is H. Pylori Antibiotic Resistance Surveillance Needed?
Is H. Pylori Antibiotic Resistance Surveillance Needed?
Background Most patients are prescribed Helicobacter pylori treatment without culture and antibiotic susceptibility testing, as current guidance recommends that patients with recurrent dyspepsia should be tested for H. pylori using a non-invasive breath or faecal antigen test.
Aims To determine the prevalence of H. pylori antibiotic resistance in patients attending endoscopy in England and Wales, and the feasibility of an antibiotic resistance surveillance programme testing.
Methods We tested the antibiotic susceptibility of H. pylori isolates from biopsy specimens from 2063 of 7791 (26%) patients attending for endoscopy in Gloucester and Bangor, and 339 biopsy specimens sent to the Helicobacter Reference Unit (HRU) in London. Culture and susceptibility testing was undertaken in line with National and European methods.
ResultsHelicobacter pylori were cultured in 6.4% of 2063 patients attending Gloucester and Bangor hospitals. Resistance to amoxicillin, tetracycline and rifampicin/rifabutin was below 3% at all centres. Clarithromycin, metronidazole and quinolone resistance was significantly higher in HRU (68%, 88%, 17%) and Bangor isolates (18%, 43%, 13%) than Gloucester (3%, 22%, 1%). Each previous course of these antibiotics is associated with an increase in the risk of antibiotic resistance to that agent [clarithromycin: RR = 1.5 (P = 0.12); metronidazole RR = 1.6 (P = 0.002); quinolone RR = 1.8 (P = 0.01)].
ConclusionsHelicobacter pylori infection is now uncommon in dyspeptic patients at endoscopy. A surveillance system is feasible and necessary to inform dyspepsia management guidance. Clinicians should take a thorough antibiotic history before prescribing metronidazole, clarithromycin or levofloxacin for H. pylori.
Helicobacter pylori causes chronic active gastritis that may be associated with symptomatic dyspepsia. Up to 40% of the adult population in developed countries have evidence of exposure to H. pylori, acquired at an early age, which is unlikely to resolve without appropriate antibiotic treatment. Eradication of H. pylori reduces the risk of peptic ulcer recurrence, helps to prevent the development of both ulcers and gastric cancer and benefits around 8% of patients with non-ulcer dyspepsia. Between 2005 and 2010 the use of drugs for dyspepsia increased by 50%.
Helicobacter pylori occupies an unusual niche on the acidic surface of the gastric mucosa and to attain successful eradication, an acid suppressant is needed (usually a proton pump inhibitor [PPI]) in combination with two or more antibiotics (triple therapy). Guidance from the National Institute for Health and Clinical Excellence (NICE) and the European Maastricht Consensus guidance recommend empiric first line treatment with a proton pump inhibitor (PPI) and clarithromycin in combination with metronidazole or amoxicillin. Treatment failures due to drug-resistant H. pylori strains have become an increasing problem and this has prompted clinicians to prescribe alternative antimicrobial regimens, with second-line treatment including tetracycline with a PPI and a bismuth salt. If third-line treatment is required, a number of studies now support the use of quinolone or rifabutin-based treatment.
Most patients are prescribed H. pylori treatment without culture and antibiotic susceptibility testing as current NICE dyspepsia guidance recommends that patients with recurrent dyspepsia should be tested for H. pylori using a non-invasive breath or faecal antigen test. The Maastricht III Consensus recommends surveillance of primary H. pylori antibiotic resistance to inform guidance for empirical first-line treatment. They also recommend that clarithromycin should no longer be prescribed for H. pylori if local resistance is above 15–20%. A two centre longitudinal UK study between 2000 and 2005 showed that H. pylori resistance to clarithromycin increased from 6% to 13%. However, our 2008 English survey showed that culture and antibiotic susceptibility testing using Epsilometer test (E-test) minimum inhibitory concentration (MIC) strips was only routinely performed on a weekly basis in two microbiology laboratories in England and Wales and in the HPA reference laboratory. As a result, very few laboratories have Clinical Pathology Accreditation (CPA) for H. pylori culture and susceptibility and there is now no formal prospective surveillance of H. pylori antibiotic resistance.
The objectives of this study were threefold: (i) to estimate antibiotic resistance in H. pylori in UK endoscopy patients, (ii) to investigate whether or not previous courses of antibiotics increased the risk of resistance and (iii) to investigate whether or not the collection procedures and number of biopsy specimens received for culture are sufficient to support a culture based surveillance system. This data will inform treatment guidance and how any future National H. pylori antibiotic resistance surveillance system should be set up.
Abstract and Introduction
Abstract
Background Most patients are prescribed Helicobacter pylori treatment without culture and antibiotic susceptibility testing, as current guidance recommends that patients with recurrent dyspepsia should be tested for H. pylori using a non-invasive breath or faecal antigen test.
Aims To determine the prevalence of H. pylori antibiotic resistance in patients attending endoscopy in England and Wales, and the feasibility of an antibiotic resistance surveillance programme testing.
Methods We tested the antibiotic susceptibility of H. pylori isolates from biopsy specimens from 2063 of 7791 (26%) patients attending for endoscopy in Gloucester and Bangor, and 339 biopsy specimens sent to the Helicobacter Reference Unit (HRU) in London. Culture and susceptibility testing was undertaken in line with National and European methods.
ResultsHelicobacter pylori were cultured in 6.4% of 2063 patients attending Gloucester and Bangor hospitals. Resistance to amoxicillin, tetracycline and rifampicin/rifabutin was below 3% at all centres. Clarithromycin, metronidazole and quinolone resistance was significantly higher in HRU (68%, 88%, 17%) and Bangor isolates (18%, 43%, 13%) than Gloucester (3%, 22%, 1%). Each previous course of these antibiotics is associated with an increase in the risk of antibiotic resistance to that agent [clarithromycin: RR = 1.5 (P = 0.12); metronidazole RR = 1.6 (P = 0.002); quinolone RR = 1.8 (P = 0.01)].
ConclusionsHelicobacter pylori infection is now uncommon in dyspeptic patients at endoscopy. A surveillance system is feasible and necessary to inform dyspepsia management guidance. Clinicians should take a thorough antibiotic history before prescribing metronidazole, clarithromycin or levofloxacin for H. pylori.
Introduction
Helicobacter pylori causes chronic active gastritis that may be associated with symptomatic dyspepsia. Up to 40% of the adult population in developed countries have evidence of exposure to H. pylori, acquired at an early age, which is unlikely to resolve without appropriate antibiotic treatment. Eradication of H. pylori reduces the risk of peptic ulcer recurrence, helps to prevent the development of both ulcers and gastric cancer and benefits around 8% of patients with non-ulcer dyspepsia. Between 2005 and 2010 the use of drugs for dyspepsia increased by 50%.
Helicobacter pylori occupies an unusual niche on the acidic surface of the gastric mucosa and to attain successful eradication, an acid suppressant is needed (usually a proton pump inhibitor [PPI]) in combination with two or more antibiotics (triple therapy). Guidance from the National Institute for Health and Clinical Excellence (NICE) and the European Maastricht Consensus guidance recommend empiric first line treatment with a proton pump inhibitor (PPI) and clarithromycin in combination with metronidazole or amoxicillin. Treatment failures due to drug-resistant H. pylori strains have become an increasing problem and this has prompted clinicians to prescribe alternative antimicrobial regimens, with second-line treatment including tetracycline with a PPI and a bismuth salt. If third-line treatment is required, a number of studies now support the use of quinolone or rifabutin-based treatment.
Most patients are prescribed H. pylori treatment without culture and antibiotic susceptibility testing as current NICE dyspepsia guidance recommends that patients with recurrent dyspepsia should be tested for H. pylori using a non-invasive breath or faecal antigen test. The Maastricht III Consensus recommends surveillance of primary H. pylori antibiotic resistance to inform guidance for empirical first-line treatment. They also recommend that clarithromycin should no longer be prescribed for H. pylori if local resistance is above 15–20%. A two centre longitudinal UK study between 2000 and 2005 showed that H. pylori resistance to clarithromycin increased from 6% to 13%. However, our 2008 English survey showed that culture and antibiotic susceptibility testing using Epsilometer test (E-test) minimum inhibitory concentration (MIC) strips was only routinely performed on a weekly basis in two microbiology laboratories in England and Wales and in the HPA reference laboratory. As a result, very few laboratories have Clinical Pathology Accreditation (CPA) for H. pylori culture and susceptibility and there is now no formal prospective surveillance of H. pylori antibiotic resistance.
The objectives of this study were threefold: (i) to estimate antibiotic resistance in H. pylori in UK endoscopy patients, (ii) to investigate whether or not previous courses of antibiotics increased the risk of resistance and (iii) to investigate whether or not the collection procedures and number of biopsy specimens received for culture are sufficient to support a culture based surveillance system. This data will inform treatment guidance and how any future National H. pylori antibiotic resistance surveillance system should be set up.
