H pylori difficult to treat !!!

We know that  A) Helicobacter pylori is a common bacteria , infecting about half of world’s population, with higher prevalence in developing countries, where H. pylori could infect up to 80% of the population , than in developed ones.H. pylori is associated with the development of gastrointestinal disorders as chronic gastritis, peptic ulcer, and gastric adenocarcinoma. H. pylori is also involved in the development of other extra-gastric disorders such as mucosa-associated lymphoid tissue lymphoma (MALT), idiopathic thrombocytopenic purpura, vitamin B₁₂ deficiency, and iron deficiency .Eradication of H. pylori , therefore could help in the management of these H. pylori-associated disorders.

B) What was the drug use earlier??  Ans:-For the last two decades, the recommended treatment for H. pylori eradication is the standard triple therapy using a proton pump inhibitor or ranitidine bismuth citrate, combined with clarithromycin and amoxicillin or metronidazole. In a recent systematic review, the global incidence of primary H. pylori resistance to clarithromycin has been reported to be as high as 17.2%, showing an increase worldwide .The prevalence of H. pylori resistance to clarithromycin varies among different countries, s During the 90s, the standard triple therapy was the gold standard in the treatment of H. pylori infections. The standard triple therapies are based on a proton pump inhibitor, clarithromycin, and amoxicillin or metronidazole. The increase in the prevalence of resistance to these antibiotics, especially to the key antibiotic, clarithromycin, has decreased the efficacy of standard regimens. Information about local resistant to antibiotics should be taken into account before establishing a treatment plan for the patient to avoid repeated treatments. Several expositions to antibiotic treatments could result in more side effects and a decrease in the percentage of antibiotic resistance.

C) What was done earlier?? During the 90’s, due to the fact that these treatments reached high eradication rates [more than 90%) together with the safety profile, these triple therapies had a very high acceptance among clinicians . The efficacy of these triple regimens has decreased lately to rates lower than 70%, due to H. pylori resistance to key antibiotics, mainly clarithromycin, but also metronidazole and levofloxacin .These low rates of successful treatment are not acceptable under the Maastricht consensus which points out that rates consistently below 80% by intention-to-treat are not acceptable for treating H. pylori .

D) What is being done now?? Ans A) Ans:-H. pylori resistance to key antibiotics, mainly clarithromycin, but also metronidazole and levofloxacin has become a problem to most clinicians globally .: Probiotics & to  combat antibiotic resistance , people have switched over to  second-line therapies that are used such as sequential therapy and quadruple therapy.. resistance rates seems to be correlated to the national level of macrolide consumption and different policies for antibiotic consumption in different countries . Based on these publications, standard triple therapies may not be recommended anymore for empiric use. However, the increase in the prevalence of macrolide resistance, mainly clarithromycin, has decreased the efficacy of these therapies to unacceptably low levels in most parts of the world, resulting in the necessity of studying other possible therapies in order to eradicate the pathogen.

These therapies are the bismuth quadruple, sequential, and hybrid therapies. Due to the rapid development of quinolone resistance, levofloxacin-based regimens should be reserved as a second-line treatment option.

Related to probiotics, probiotics could not be recommended to be used as a single agent for eradication therapy. However, their use associated to standard treatment as an adjunct will improve the eradiation rates and decrease treatment-related side effects.

 Due to the high level of resistance to the two key antibiotics of standard triple therapies, clarithromycin and metronidazole, and the different patterns of resistance in different populations, standard triple therapies should be adapted to the local resistance pattern, and when possible, treatment should be based on susceptibility data obtained by testing the strain after culture.

Alternative strategies are being implemented in clinical practice to treat H. pylori-resistant strains. This included development and use of novel and more effective treatments and use of probiotics to improve the eradication regimens and decrease the antibiotic side effects.

Probiotics are defined as living microbial species that can include anti-inflammatory and anti-oxidative mechanisms that may improve bowel microecology and general health. Probiotics are live microorganisms, which when administered in adequate amounts confer a health benefit on the host. The most used probiotic bacteria are Lactobacillus and Bifidobacterium .Probiotics could improve H. pylori eradication and reduce side effects during therapy..

New macrolides were marketed in Europe at the beginning of the 90’s; patients were exposed to macrolides in order to treat respiratory infections with antibiotics of this group.