NEW YORK (Reuters Health) – Primary antibiotic resistance in Helicobacter pylori varies widely among countries in the Asia Pacific, suggesting that treatment strategies should be adapted to each country’s resistance pattern, according to newly published research.
Dr. Ming-Shiang Wu of National Taiwan University and colleagues searched the literature for articles published between 1990 and 2016 on primary antibiotic resistance to H. pylori in the Asia-Pacific region and the efficacy of first-line regimens.
The team also did subgroup analyses by country and study period (i.e., before 2000, 2001-2005, 2006-2010, and 2011-2015).
As reported online August 3 in The Lancet Gastroenterology and Hepatology, 176 articles from 24 countries were included in the antibiotic resistance analysis. The overall mean prevalences of primary H. pylori resistance were 17% for clarithromycin, 44% for metronidazole, 18% for levofloxacin, 3% for amoxicillin, and 4% for tetracycline.
In the subgroup analyses, prevalence varied by country. For example, for metronidazole, the prevalence was 57% in Australia, 10% in Japan, and 39% in Singapore; for levofloxacin, resistance prevalence was 6% in India, 17% in Hong Kong, and 36% in China.
Prevalence also varied somewhat over time: The overall prevalence of resistance to clarithromycin and levofloxacin rose significantly from the earliest study period to the most recent – for clarithromycin, from 7% to 21%; for levofloxacin, from 2% to 27%. Resistance to metronidazole increased from 36% to 45%, but that change was not statistically significant. Changes for amoxicillin and tetracycline were small.
The analysis of efficacy of first-line therapies included 170 articles from 16 countries. Unsatisfactory efficacy (<80%) was noted with clarithromycin-containing regimens in countries where clarithromycin resistance rates were higher than 20%.
In a joint email to Reuters Health, Dr. Wu and Taiwan National University colleagues Dr. Jyh-Ming Liou and Dr. Yu-Ting Kuo, and Dr. Yoshio Yamaoka of Oita University, Japan, said the wide variance in antibiotic resistance among the Asia-Pacific countries and “unsatisfactory efficacy” of clarithromycin-containing regimens in certain countries “collectively indicate that the treatment strategy should be adapted relative to country-specific resistance patterns.”
“Information about (prevalence) was scarce in some countries, including Bangladesh, Nepal, Russia, Indonesia, Bhutan, Myanmar, Malaysia, Mongolia, and various Middle East countries,” they noted. “More prospective studies using similar study protocols are warranted to continuously survey the antibiotic resistance rate in (the) Asia-Pacific region.”
Dr. Louis Cohen of The Mount Sinai Hospital in New York City told Reuters Health, “H. pylori infections continue to present a clinical conundrum for physicians who are faced with treatment decisions surrounding these bacteria.”
“The study demonstrates that rates of antibiotic resistance have been rising in Southeast Asia,” he said by email. “While the finding . . . is concerning, the study does not make clear whether this translates into negative clinical outcomes – i.e., a rise in certain gastric cancers, refractory peptic ulcer disease, and so forth.”
“Antibiotic resistance in H. pylori is well documented and part of why standard antibiotic therapies for it involve two or more antibiotics,” he continued. “High rates of resistance as well as (the bacteria’s) potential role as a commensal organism have also led to recommendations not to test for it in certain clinical scenarios where treatment is unlikely to have benefit.”
“The real question the field must answer is when H. pylori should be treated and in whom,” Dr. Cohen said.
The rise in resistant organisms should, he added, “give physicians pause before prescribing antibiotics for indications for which they often are not warranted.”
“As the authors point out,” he said, “in places like Southeast Asia, where antibiotics can often be secured without a physician, the practices that lead to antibiotic-resistant organisms may be far more complex.”
“It will be increasingly important to understand how the transmission of antibiotic-resistant organisms occurs on a large scale,” Dr. Cohen concluded, “and to continue to develop practices in the clinic and potentially in larger-scale sanitation processes to prevent these organisms from transferring from one reservoir to another.”
SOURCES: http://bit.ly/2wdC0C4 and http://bit.ly/2w5q3hw
Lancet Gastroenterol Hepatol 2017.
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