Journal of Global Antimicrobial Resistance 19 (2019) 194–200 Contents lists available at ScienceDirect Journal of Global Antimicrobial Resistance journal homepage: www.elsevier.com/locate/jgar Refractory Helicobacter pylori gastritis: The hidden predictors of resistance Amr Shaaban Hanafy*, Waseem M. Seleem Internal Medicine Department, Endoscopy Unit, Gastroenterology and Hepatology Division, Zagazig University, Zagazig, Sharqia 44519, Egypt A R T I C L E I N F O A B S T R A C T Article history: Objectives: Failure of Helicobacter pylori eradication is documented in 20% of patients. Some patients show Received 15 February 2019 a negative faecal antigen test (FAT) with persistent symptoms after therapy. The aim of this study was to Received in revised form 3 May 2019 detect occult H. pylori infection in patients with persistent symptoms despite FAT negativity following Accepted 9 May 2019 therapy. Available online 18 May 2019 Methods: A total of 200 symptomatic patients presenting with dyspepsia and positive FAT were treated with H. pylori triple therapy for 2 weeks. Refractory patients received levofloxacin-based salvage therapy. Keywords: Upper gastrointestinal endoscopy was performed for patients with persistent symptoms despite negative Refractory infection FAT after salvage therapy. Gastric biopsies were exposed to rapid urease test and RFLP-PCR for Faecal antigen test clarithromycin resistance in domain V of 23S rRNA (2142/2143 point mutations) as well as culture and Clarithromycin resistance Helicobacter pylori antimicrobial susceptibility testing (AST). Culture Results: A total of 136 patients responded to classic triple therapy with negative FAT, and 15 patients showed persistent symptoms with positive FAT and received salvage therapy. The remaining 49 patients showed persistent symptoms despite negative FAT, therefore gastric biopsies with rapid urease test were performed. Clarithromycin resistance was confirmed in 12/49 patients (24.5%). Cultures were most commonly susceptible to norfloxacin (n = 18), moxifloxacin (n = 13), doxycycline (n = 11) and amikacin (n = 8). Non-responders with negative FAT had moderate or severe fatty liver disease (26.5% and 32.7%, respectively), 40.9% had hepatitis C virus (HCV) infection, and they had significantly higher HOMA-IR and HbA1c. Conclusion: Diabetes mellitus, HCV and non-alcoholic fatty liver disease predispose to refractory H. pylori requiring culture and AST. © 2019 International Society for Antimicrobial Chemotherapy. Published by Elsevier Ltd. All rights reserved. 1. Introduction acid secretion and the development of intestinal metaplasia, glandular atrophy and hypochlorhydria [5]. Helicobacter pylori is considered a public-health problem as it is Pathogenic factors of H. pylori are the presence of flagella, involved in the development of duodenal and gastric ulcers, gastric urease enzyme production, mucosal adherence by bacterial cancer, gastric mucosa-associated lymphoid tissue (MALT) lym- adhesin (BabA), mediation of tissue injury by lipopolysaccharide phoma and gastric adenocarcinoma [1]. that interacts trefoil factor 1 to promote colonisation, effector H. pylori is a flagellate, Gram-negative, spiral-shaped bacterium protein cytotoxin-associated gene A (CagA), vacuolating cytotoxin with microaerophilic behaviour [2,3]. Infection with H. pylori is (VacA), outer inflammatory protein (OipA) and duodenal ulcer- commonly acquired during childhood and the methods of promoting protein A (DupA). transmission are mainly person-to-person and interfamilial [4]. In addition, H. pylori reduces the production of heat shock Acid secretion is increased in antrum-predominant gastritis, proteins leading to immune evasion with long-term colonisation whereas corpus-predominant gastritis is characterised by reduced [6]. The predominant immunological mechanisms in H. pylori infection are the Th1 immune response triggered by interleukin 12 (IL-12) and IL-18 following H. pylori antigen presentation and recognition by gastric epithelial cells, dendritic cells and macrophages with enhanced production of Th1-dominated * Corresponding author. cytokines such as tumour necrosis factor-alpha (TNFα), IL-1β E-mail addresses: [email protected], [email protected] (A.S. Hanafy). and interferon-gamma (IFNg) [7]. https://doi.org/10.1016/j.jgar.2019.05.015 2213-7165/© 2019 International Society for Antimicrobial Chemotherapy. Published by Elsevier Ltd. All rights reserved. A.S. Hanafy, W.M. Seleem / Journal of Global Antimicrobial Resistance 19 (2019) 194–200 195 Mechanisms of refractory H. pylori are the presence of Declaration of Helsinki as reflected in a priori approval by the clarithromycin- and metronidazole-resistant strains (30% and institution’s Human Research Committee. 30–60% of cases, respectively) [8], previous macrolide experience, patient non-compliance, and failure of adequate acid suppression 2.2. Biochemical investigations that promotes H. pylori to become more susceptible to antimicro- bial therapy [9]. 2.2.1. Laboratory investigations Although classic triple therapy is effective, it is associated with The following laboratory investigations were performed: liver treatment failure in 20–30% of patients [10] or even higher in real- and kidney function tests; complete blood count; fasting and life clinical practice [11,12]. postprandial blood glucose; HbA1c level; and fasting insulin, H. pylori shows oncogenic behaviour. Eradication reduces the which was measured quantitatively by electrochemiluminescence gastric cancer incidence by 39% and reverses atrophic gastritis in immunoassay with a cut-off value 8.64 mIU/mL. 50%, therefore confirmed H. pylori infection should be treated even Insulin resistance was calculated by Homeostatic Model in asymptomatic patients [13,14]. Assessment of Insulin Resistance (HOMA-IR) using the following Poor glycaemic control had been found to increase the risk formula: fasting glucose (mg/dL) Â fasting insulin (mIU/mL)/405; a of persistence and the carcinogenic effect of H. pylori. Ikeda value >2 indicates insulin resistance [18,19]. et al. reported a greater risk of gastric cancer in those with high haemoglobin A1c (HbA1c) 6% and co-existent H. pylori infection 2.2.2. Association with other infections [15]. The possible association of other infections in resistant cases of Chronic hepatitis C virus (HCV) infection is associated with H. pylori was determined by detection of HCV antibody for HCV H. pylori in nearly 40% of patients. Its possible localisation in the infection and hepatitis B surface antigen (HBsAg) for hepatitis B gastric microenvironment might induce the persistence of H. pylori virus (HBV) infection. Cases with positive serology underwent and may trigger the occurrence of gastric non-Hodgkin's quantitative PCR. lymphoma [16]. The aim of the current study was to determine the incidence of 2.2.3. Monoclonal H. pylori faecal antigen test (FAT) occult H. pylori infection in gastric biopsies obtained by upper Stool samples (100 mL) were tested using enzyme immunoas- gastrointestinal endoscopy in patients with persistence of say kits (ACON Laboratories Inc., San Diego, CA, USA) according to symptoms following classic triple therapy despite a negative the manufacturer’s instructions. Positive H. pylori infection status faecal antigen test (FAT). was determined as an H. pylori stool antigen 55 ng/mL. The inter- and intra-assay coefficients of variation of the assay were 2. Materials and methods both <5%. The test was performed 6 weeks after first-line or salvage therapy. 2.1. Patient selection 2.3. Abdominal ultrasound This was an observational study conducted from May 2016 to June 2018 in the Gastroenterology Outpatient Clinic and Endosco- Patients with refractory H. pylori were examined for other py Unit of the Internal Medicine Department of Zagazig University causes of dyspepsia and abdominal pain such as fatty liver disease, Hospital, which is a tertiary referral centre in Zagazig, Egypt. A total liver cirrhosis, gallstones and pancreatic disorders. of 200 patients with epigastric pain and dyspepsia with positive FAT for H. pylori were treated with tripe therapy of esomeprazole 2.4. Upper gastrointestinal endoscopy 40 mg once daily, amoxicillin 1 g twice daily and clarithromycin 500 mg twice daily for 2 weeks. A minimum of four biopsy specimens were obtained from the Patients were evaluated by taking a complete history, physical proximal and distal stomach to establish histological H. pylori examination and symptom assessment by the Quality of Life in eradication, as infection mostly had a patchy localisation. Reflux and Dyspepsia (QOLRAD) questionnaire, which is composed of five domains: emotional distress (score, 6–41); sleep distur- 2.5. Rapid urease test bance (score, 5–35); vitality (score, 3–21); food/drink problems (score, 6–40); and social/physical functioning (score, 5–35), giving The rapid urease test, also know as the CLO (Campylobacter-like a total possible score of 25–172, with a lower value indicating a organism) test, detects the presence of urease in the gastric more severe impact on daily activities [17]. mucosa. The rapid urease test was performed during endoscopy Patients with persistent symptoms as assessed by QOLRAD and and the tissue was placed into a medium containing urea and a persistently positive FAT performed 6 weeks after finishing first- colour indicator; yellow (negative) and red (positive) discolor- line therapy underwent abdominal ultrasound to rule out more ations were assigned. The rapid urease test was performed