COST-EFFECTIVENESS ANALYSIS OF ANTIBIOTIC SUSCEPTIBILITY TESTING (AST) IN PATIENTS WITH <i>HELICOBACTER PYLORI </i>TREATMENT FAILURE: A LARGE POPULATION-BASED STUDY (COST-EFF-HP TRIAL)

Introduction. Our previous study reported a significant increase in metachronous recurrence of early gastric cancer after endoscopic submucosal dissection due to CD44v9-positive cancer stem-like cells in H. pylori-infected stomach tissue (Br. J. Cancer 109:379, 2013). Additionally, we demonstrated development of CD44v9-positive cells due to overexpression of capping actin protein of muscle Z-line alpha subunit 1 (CAPZA1) by cells that accumulated H. pylori-derived CagA oncoprotein (Autophagy 15:242, 2019; Cell. Mol. Gastroenterol. Hepatol. 8:319, 2019); CAPZA1 expression is significantly increased by histone deacetylase (HDAC) inhibitors (Autophagy 15:242, 2019). Short-chain fatty acids (SCFAs), a subset of key gut-commensal metabolites, inhibit HDAC (J. Biol. Chem. 253:3364, 1978) and may induce CAPZA1 overexpression in H. pylori-infected gastric mucosa, resulting in the development of CD44v9-positive cells. To test this, we examined whether SCFAs mediate production of CD44v9-positive cells via upregulation of CAPZA1 expression in H. pylori infection, and searched for SCFA-producing bacteria in gastric cancer patients by a Taq amplified (TA) cloning and sequencing technique using a 16S rRNA library of gastric commensal bacteria.
Methods. A 16S rRNA library derived from gastric juice was constructed by TA cloning and sequenced by the Sanger method. H. pylori G27 and G27 cagPAI-deletion mutant strains were used. Gastric epithelial monolayers (mucosoids) were made from gastric organoids (Gut 68:400, 2019).
Results. Butyrate enhanced CAPZA1 expression in AGS cells and mucosoids via enhanced histone acetylation at the CAPZA1 promoter region. CD44v9 expression was induced in CAPZA1-overexpressing cells accumulating CagA secreted by H. pylori. CD44v9-positive cells expressed LGR5, KLF5, and SALL4, suggesting that butyrate imparts stem-cell properties to CD44v9-expressing cells. Specific SCFA-producing bacteria, Streptococcus spp., in stomachs of gastric cancer patients were identified as non-Helicobacter bacteria and their 16S rRNA levels were significantly higher in gastric cancer patients than in controls (AUROC = 0.83 [95% CI, 0.65–1.00]). Butyrate synthesizing gene butCoAT expression in Streptococcus spp. was significantly greater by 2-fold compared with that in E. coli, indicating that Streptococcus spp. have a superior ability to produce butyrate. Culture supernatant of Streptococcus spp. increased expression of CAPZA1 in AGS cells, suggesting that co-infection by Streptococcus spp. and H. pylori increases the risk of CD44v9-positive cancer-stem cell production.
Conclusion. Butyrate produced by Streptococcus spp. fosters development of CD44v9-positive cancer stem-like cells in H. pylori-infected stomach tissue through the enhancement of CAPZA1 expression.

Helicobacter pylori is the strongest known risk factor for gastric cancer, and pathologic outcomes are mediated via complex interactions among H. pylori virulence determinants, host immune responses, and the exposome. One virulence determinant that augments cancer risk is the cag pathogenicity island (PAI), and strains harboring this constituent induce more severe gastric injury. The cag PAI encodes a type IV secretion system (T4SS) that translocates the oncoprotein, CagA, into host cells and activates signaling cascades that mediate neoplastic transformation. One host factor that is a key transcriptional regulator of immunity and carcinogenesis is HIF-1α. To define the role of this effector in gastric carcinogenesis in humans, levels of HIF-1α were assessed in gastric biopsies from patients with non-atrophic gastritis (N=8), multifocal atrophic gastritis (N=10), intestinal metaplasia (N=14), and gastric cancer (N=10). Levels of HIF-1α significantly increased in parallel with increasing severity of gastric lesions, with highest expression levels observed in patients with gastric cancer. In interventional studies targeting HIF-1α in H. pylori-induced inflammation and injury in vivo, C57BL/6 mice were treated with or without dimethyloxalylglycine (DMOG), a cell-permeable prolyl hydroxylase (PHD) inhibitor that can decrease HIF-1α-induced inflammation, for one week prior to infection with the H. pylori cag⁺ strain PMSS1. Mice were euthanized eight weeks post-challenge and gastric tissue was harvested for quantitative culture, immunohistochemistry, histopathology, and chemokine/cytokine analyses. DMOG treatment had no effect on H. pylori colonization. As expected, H. pylori induced gastric inflammation in vehicle-treated mice; however, this was significantly attenuated (P<0.05) in H. pylori-infected mice pretreated with DMOG. Similarly, H. pylori significantly increased mucosal levels of inflammatory chemokines (KC: 1.5-fold; MIP-1β: 1.9-fold; RANTES: 1.6-fold) and cytokines (INF-γ: 1.8-fold; IL-1β: 3.8-fold; IL-6: 1.9-fold) in vehicle-treated mice relative to uninfected controls, but this response was significantly inhibited (P<0.05) in DMOG-treated mice infected with H. pylori. Further, DMOG treatment significantly attenuated H. pylori cag T4SS function in vivo, whereby 50% of DMOG-adapted isolates lost the ability to translocate CagA compared to only 20% of isolates from vehicle-treated mice. In vitro mechanistic studies demonstrated that DMOG treatment also significantly reduced (P<0.01) cag T4SS-mediated NF-κB activation and IL-8 induction. Collectively, these data indicate that PHD inhibition targeting HIF-1α is protective against the development of pathologic responses that arise within the context of H. pylori infection, and is mediated, in part, via attenuation of H. pylori virulence as well as suppression of host proinflammatory responses.

BACKGROUND: Point mutations of the H. pylori 23S rRNA and gyrase A genes are associated with clarithromycin and levofloxacin resistance, respectively. However, it is uncertain if the H. pylori eradication rate using molecular testing guided therapy (MTGT) is non-inferior to that of susceptibility testing guided therapy (STGT).
METHODS: Two multi-center, open label, randomized controlled trials were conducted in Taiwan, in which treatment-naïve H. pylori-positive patients were included in Trial 1 and patients with refractory H. pylori infection were included in Trial 2. Eligible patients were allocated in a 1:1 ratio to receive either MTGT or STGT. Agar dilution test was used in the STGT group to determine the minimum inhibitory concentrations (MICs) of clarithromycin and levofloxacin, and the 23S rRNA and gyrase A mutations determined by polymerase chain reaction and direct sequencing were used in the MTGT group. Eradication efficacy and adverse effects were assessed according to Intent-to-treat (ITT) and per protocol (PP) analyses. The margin of 5% and 10% were used for non-inferiority analysis in Trial 1 and Trial 2, respectively. The trials were registered with ClinicalTrials.gov (NCT03556254 for Trial 1 and NCT03555526 for Trial 2).
RESULTS: Study participants received clarithromycin sequential or levofloxacin sequential or bismuth quadruple therapy according to resistance to clarithromycin and levofloxacin detected by either molecular or MICs methods. A total of 560 treatment-naïve patients were enrolled in Trial 1, and another 320 patients with refractory H. pylori infection were recruited in Trial 2 (Table 1). In first-line treatment, the eradication rates were 86.1% (95% CI: 82.0%-90.1%) versus 86.8% (95% CI: 82.8%-90.8%) in the MTGT group and STGT group (p-value=0.805), respectively (Table 1). In third-line H. pylori treatment, the eradication rates were 88.1% (95% CI: 83.1%-93.1%) versus 86.9% (95% CI: 81.6%-92.1%) in MTGT group and STGT group in the ITT analysis (p-value=0.735), respectively. The difference of the eradication rate for MTGT compared to STGT was -0.7% (95% CI: -6.4%-5.0%) in Trial 1 and 1.3% (-6.0%-8.5%) in Trial 2 by ITT analysis (Figure 1). Meta-analysis of the two trials showed that the overall risk difference was -0.03% (95% CI: -4.4%-4.5%) in ITT analysis. There were no significant differences in the adverse events between the two treatment groups in both trials.
CONCLUSION The eradication rates using molecular testing guided therapy were not inferior to susceptibility testing guided therapy in first-line and third-line treatment for H. pylori infection, lending support to the use of molecular detection of antibiotic resistance in the treatment of H. pylori infection.

Background: obesity is a global chronic pandemic in many countries and is a significant risk factor for Helicobacter pylori (H pylori) eradication failure. The reason of this poor eradication remains to be elucidated, but the physiological changes that obesity produces may lead to sub-therapeutic antibiotics concentrations. Most antibiotics are given in a fixed-dose basis and the current paradigm “one dose fits all“ risks underdosing obese individuals. H pylori dosing recommendations are based on Clinical Trials in which obese patients are under-represented or excluded and evidence-based dosing guidelines are lacking. H pylori is very sensitive to amoxicillin and usually does not develop resistance to it. In addition, amoxicillin is a safe drug and has a wide therapeutic window. Ideally, the “one dose fits all” paradigm should be replaced by individualised dosing methods. The aim of the study was to evaluate weather a high-dose amoxicillin regimen influences the success rates eradication of H.pylori in obese patients using data of two multicenter, prospective studies of our research group. Methods: the post-hoc analysis included 180 naïve H pylori obese patients undergoing bariatric surgery. All patients were treated 14 days with a Quadruple Concomitant therapy with a proton pump inhibitor, amoxicillin, metronidazole and clarithromycin. 40 obese patients (group 1) received a high-dose amoxicillin regimen based on the body weight (50mg/Kg/day) and 140 obese patients (group 2) received the standard quadruple concomitant therapy at fixed doses or did not reach the target dose (50mg/Kg/day). Upper endoscopy and H pylori assessment by histology was performed at baseline and the eradication status was assessed by C13 Urea Breath Test 6-8 weeks after the end of therapy. Eradication efficacy was performed by the Intention-to-treat (ITT) analysis. Results: successfull eradication was observed in 90% (36/40, 95% CI 80-100) obese patients in the group 1(high-dose amoxicillin) compared with 66% (92/140, 95% CI 58-74) in Group 2. There was a significant difference eradication rate between the groups (P < 0.05). The Odds ratio was 4.69 (1.57-13.9) and the risk difference was 24.29% (12.11-36.46). The distribution of age, gender, smoking, diabetes and adverse events did not differ significantly between the two groups. Conclusion: a tailored Quadruple Concomitant therapy based on a high-dose amoxicillin significantly improved the eradication rate in obese patients undergoing bariatric surgery. New strategies of eradication are needed principally in morbid obesity and the current paradigm “one dose fits all“ should be changed by individualised dosing methods

Background: Due to general unavailability and common side effects of tetracycline, the clinical application of bismuth quadruple therapy (BQT) is greatly limited. Whether amoxicillin can replace tetracycline in BQT remains unknown. This study aimed to compare the eradication rate, safety and compliance between amoxicillin-containing and tetracycline-containing BQT as a first-line regimen for Helicobacter pylori eradication.
Methods: This randomised trial was conducted on 404 naïve patients with H. pylori infection. The participants were randomly assigned to 14-day amoxicillin-containing (bismuth potassium citrate 110 mg four times/day, esomeprazole 20 mg twice daily, metronidazole 400 mg four times/day and amoxicillin 500 mg four times/day) and tetracycline-containing (tetracycline 500 mg four times/day and the other three drugs used as above) BQT. Safety and compliance were assessed within 3 days after eradication. Urea breath test was performed 4–8 weeks after eradication to evaluate outcome.
Results: As for the eradication rates of amoxicillin-containing and tetracycline-containing BQT, the results of both intention-to-treat and per-protocol analyses showed that the difference rate of the lower limit of 95% confidence interval was above −10.0% (intention-to-treat analysis: 81.7% vs. 83.2%, with a rate difference of −1.5% [−6.3%–9.3%]; per-protocol analysis: 89.0% vs. 91.6%, −2.6% [−4.1%–9.3%]). The incidence of adverse events in amoxicillin-containing BQT was significantly lower than tetracycline-containing BQT (29.5% vs. 39.7%, P=0.032). Both groups achieved relatively good compliance (92.0% vs. 89.9%, P=0.475). Univariate analysis indicated that the eradication rate was significantly higher in compliant patients than in noncompliant patients (89.0% vs.50.0% in amoxicillin-containing BQT, P=0.010; 91.6% vs. 50.0% in tetracycline-containing BQT, P=0.001). Moreover, sex, age, body mass index, smoking, alcohol drinking, diagnosis or antibiotic resistance failed to show a significant effect on the eradication rates in both groups.
Conclusion: The eradication efficacy of amoxicillin-containing BQT was non-inferior to tetracycline-containing BQT as a first-line regimen for H. pylori eradication with better safety and similar compliance.

Keywords:
amoxicillin; tetracycline; bismuth quadruple therapy; Helicobacter pylori

BACKGROUND: H. pylori eradication is recommended to prevent gastric cancer. Increased multidrug-resistant (MDR) strains have become a global threat resulting in treatment failure. This study aimed to determine factors associated with H. pylori treatment failure and cost-effectiveness analysis of antibiotic susceptibility testing (AST) for H. pylori eradication.
METHODS: Dyspeptic patients undergoing gastroscopy at tertiary care center in Thailand were enrolled between August 2014 and October 2022. Treatment failure was defined as persistent H. pylori infection after completing ≥1 eradication regimen. Early AST was defined as AST performed after first-line treatment failure but before second-line treatment. Patients’ demographic data, endoscopic findings, H. pylori culture, AST, treatment regimens, and medication costs were extracted from medical database and extensively reviewed.
RESULTS: Of 1,070 patients with H. pylori infection, 310 had treatment failure with the mean age of 58.4 years and 44.8% were males. AST was performed in 79 strains demonstrating resistance to levofloxacin (55.7%), metronidazole (54.4%), clarithromycin (45.6%), and amoxicillin (5.1%). Multivariate analysis demonstrated that presence of MDR H. pylori strains (46.8% vs. 17.4%; OR 4.36, 95%CI 2.26-8.39, p<0.001) and sequential therapy as first-line treatment (9.7% vs. 5.8%; OR 1.73, 95%CI 1.06-2.80, p=0.028) were significantly associated with treatment failure, while vonoprazan-based therapy as first-line regimen was a protective factor for treatment failure (9.7% vs. 14.3%; OR 0.63, 95%CI 0.41-0.97, p=0.035). Early AST was performed in 23 patients, whereas 56 had AST after treatment failures. All patients with early AST achieved treatment success by third-line eradication. Patients without AST experienced a gradual decline in eradication rates from 65.2% to 60% after multiple eradication attempts, while patients with AST after treatment failures had increasing cure rates and eventually achieved higher eradication rates than those without AST after multiple eradication therapies (94.4% vs. 60%, p=0.02) as demonstrated in figure 1. Early AST could provide significantly lower mean medication costs than AST after treatment failures (65 USD vs. 215 USD, p<0.001).
CONCLUSION: Vonoprazan-based therapy was an effective first-line regimen to prevent treatment failure. Early AST is highly cost-effective for treatment of H. pylori eradication failure to predict favourable outcome and prevent unnecessary antibiotic use.