The eradication therapy of
For many years the first-line therapy recommended by the international guidelines in eradication of
During the last years, the widespread use/abuse of antibiotics, particularly for respiratory tract infections, led to the emergence of increasing resistance of
Actually, before starting an eradication treatment, we should also consider the resistance to quinolones because it is increasing worldwide over the last years [
Besides, also the resistance to metronidazole is often high, but it can be overcome by increasing the duration of treatment or by prescription of bismuth-containing quadruple therapy including metronidazole [
Culture is the most common and specific invasive diagnostic method to detect the antimicrobial susceptibility of
In children ESPGHAN/NASPGHAN guidelines recommend antibiotic susceptibility testing for clarithromycin before starting clarithromycin-based triple therapy in areas/populations with a known high resistance rate (>20%) [
The most common antibiotics used in
Therefore, looking for the best eradication therapy, if the antimicrobial susceptibility is not available, we should ask patients which and how many antibiotics they used before, because previous antibiotics could negatively influence the efficacy of
We wanted to evaluate the variations in primary antibiotic susceptibility over the last 13 years in children with
From January 2011 to December 2012 we diagnosed by endoscopy and histological examination 66 naïve children with
Demographic characteristics of patients.
Sex | Range (months) | Mean age |
---|---|---|
Male: 37 pts and female: 29 pts | 39–192 months | 9 years and 8 months |
Clinical and endoscopical characteristics of patients are reported in Table
Clinical and endoscopical characteristics of patients.
Symptoms | Endoscopical aspects | ||
---|---|---|---|
Recurrent abdominal pain | 27 pts (40.9%) | Nodular Gastritis | 52 pts (78.7%) |
Epigastric pain | 19 pts (28.8%) | Duodenal Ulcer | 3 pts (4.5%) |
Vomiting | 9 pts (13.6%) | Duodenal Erosion | 2 pts (3%) |
Gastric pyrosis | 6 pts (9.1%) | Nodular Duodenitis | 9 pts (13.6%) |
Anemia | 5 pts (7.6%) |
Most of patients were subjected to EGDS because of recurrent abdominal pain (40.9%) and the most representative endoscopic feature was nodular gastritis.
Endoscopic biopsy specimens were taken in all subjects for histology following Sydney Criteria (two from the gastric antrum and two from the gastric corpus-fundus) and microbiological culture (one from the antrum).
The biopsy specimens for histology were fixed in formalin, embedded in paraffin, sectioned, and stained with haematoxylin-eosin. The biopsy specimens for the bacterial culture were immediately placed in an appropriate transport medium (Portagerm-Pylori, bioMérieux, France) and then homogenised and cultured on both selective (Pylori agar, bioMérieux) and nonselective (10% horse blood agar, Kima, Italy) media. After seven days of incubation at 37°C under microaerophilic conditions, typical oxidase and catalase positive colonies were identified by API Campy strips (bioMérieux) and subsequently tested for antibiotic sensitivity (
Differences in antibiotic resistance.
Antibiotic | MIC interpretative values | Resistance rate | Resistance rate |
|
---|---|---|---|---|
( |
(years 1998-99) | (years 2011-12) | ||
Metronidazole | >16 | 35 (56%) | 15 (33%) | 0.014 |
Clarithromycin | >4 | 10 (16%) | 12 (26%) | 0.142 |
Ampicillin | >4 | 2 (3%) | 0 | ns |
Tetracyclines | >16 | 1 (2%) | 0 | ns |
Metronidazole + clarithromycin | 5 (8%) | 3 (7%) | ns | |
|
||||
Total | 63/75 (84%) | 46/66 (70%) | 0.079 |
Histologically all patients had chronic nonatrophic gastritis.
Culture developed in 46/66 patients (70%) with a reduction of 14% compared to those performed 13 years before with no statistically significant value.
Throughout the last 13 years, we obtained a significant reduction in metronidazole resistance (56% versus 33%), while the clarithromycin resistance evidently increased though with no statistically significant value (16% versus 26%) (Table
During these years, the resistance to ampicillin has been confirmed to be very low or absent as well as that to tetracyclines; in the same way the combined resistance to metronidazole and clarithromycin together has not been changed, staying very low.
The eradication of
To know the local prevalence of antibiotic resistance is important also for choosing the better therapy mainly if the antimicrobial susceptibility does not develop from the culture [
Culture of
Culture can turn out to be negative even in the presence of positive urease test despite three biopsy samples took, as shown by Porowska et al [
On the contrary, other Italian researchers obtained very high culture development rate of 94% in adult patients using two antral biopsies for culture examination [
Chronic PPI intake is considered to be the main cause of culture failure and when considering options for susceptibility testing, biopsy specimens should also be taken from the gastric body [
But altogether, perhaps the main reason affecting the culture development remains the intrinsic difficulty of this technique [
Treatment failures due to drug-resistant
Thus, we should pay more attention to treatment by knowing the local antimicrobial susceptibility prevalence for increasing the successful eradication rate. Therefore clarithromycin-based triple therapy should be performed only if susceptibility testing in the individual patient revealed a clarithromycin-susceptible strain or if local clarithromycin resistance rate is known to be low (<10%) as recommended by last Maastricht [
Comparing our study with the previous one published in 2001, we obtained both a clear decrease in culture development rate and some changes in antibiotic resistance rate over the last 13 years. Metronidazole resistance decreased (from 56% to 33%) with statistically significant value, and that of clarithromycin increased (16% to 26%) (no statistically significant difference). However the frequency of both clarithromycin and metronidazole resistant strains together did not statistically change as also reported in a study from South Korea and Austria. [
Also Kalach and coworkers showed a decrease in metronidazole resistant strains but they did not get changes in clarithromycin resistance in French children over 11 years [
In our study, we confirmed that the resistance rate of
It is well established that one of the main causes of
In this study we confirmed the high resistance rate to clarithromycin in Italy [
In our centre, we took a single biopsy specimen from the antrum for the
But considering the difficulty of
In conclusion, as stated by many authors, we would like to stress the concept that, before recommending
The authors declare that there is no conflict of interests regarding the publication of this paper.