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admin | What Antibiotics Treat Bv | 05.05.2014
Approximately one-half of the world’s population is estimated to be infected with Helicobacter pylori, a gram-negative, curved bacterial rod, which has been associated with symptoms ranging from peptic ulcer disease and dyspepsia to gastric adenocarcinoma and mucosa-associated lymphoid tissue (MALT) lymphoma. The currently available diagnostic assays for detection of H pylori can be classified as either invasive, requiring gastric endoscopy and tissue biopsy, or noninvasive, requiring readily available specimen types (ie, serum, breath, and stool samples). Following recovery of 1 or more gastric tissue biopsies, evaluation for the presence of H pylori can be accomplished by 1 of 4 methods—culture, rapid urease tests, histopathology, or molecular testing (Table).
Isolation of H pylori by culture of a biopsy specimen is definitive evidence of active infection and isolates can subsequently be tested for susceptibility to various antimicrobial agents (Figure 1). Rapid urease tests (RUTs) are based on a pH color indicator system and are designed to detect the presence of urease, an enzyme produced by H pylori that metabolizes urea to ammonia and carbon dioxide.
Similar to culture, the detection of H pylori in gastric biopsies by histopathologic evaluation is considered diagnostic for active infection (Figure 2). Finally, molecular evaluation of biopsy specimens for the presence of H pylori DNA by real-time polymerase chain reaction (RT-PCR) is promising and numerous studies have found increased sensitivity and specificity of this method compared to culture, RUTs, and histopathology. Similar to the RUT, the principle behind the urea breath test (UBT) is based on production of urease by H pylori and a positive result is indicative of active infection.
The clinical sensitivity and specificity of the UBT to detect active H pylori infection exceeds 93% in most studies, though a few reports indicate potential cross-reactivity with other gastric urease-producing organisms.3-6 A distinct advantage of this assay is that it can also be used to determine treatment efficacy. Despite the excellent performance characteristics, the utility of the UBT is limited by a number of factors. The stool antigen test (SAT) is an enzyme immunoassay (EIA) designed to detect H pylori in fecal specimens by measuring H pylori antigen released from organisms lining the stomach wall (Figure 4). Despite these advantages, serologic testing for antibodies to H pylori should be ordered and results should be considered with significant caution.
To minimize improper diagnosis and unnecessary treatment regimens, providers are strongly encouraged to amend their testing strategies by replacing serologic evaluation of patients with suspected H pylori infection, with either the UBT or the SAT assay.
To conform to current H pylori testing guidelines and to improve patient management, leadership from Mayo Clinic’s divisions of Clinical Microbiology and Gastroenterology worked together to update our algorithm to detect H pylori infection. In conclusion, this article outlines the advantages and limitations of the available invasive and noninvasive testing methods to diagnose H pylori infection. Brandi G, Biavati B, Calabrese C, et al: Urease-positive bacteria other than Helicobacter pylori in human gastric juice and mucosa. Chey WD, Metz DC, Shaw S, et al: Appropriate timing of the 14C-urea breath test to establish eradication of Helicobacter pylori infection.
Chey WD, Wong BC: American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Loy CT, Irwig LM, Katelaris PH, Talley NJ: Do commercial serological kits for Helicobacter pylori infection differ in accuracy? Due to the potentially severe consequences of infection, accurate diagnosis and prompt initiation of therapy are important for successful disease resolution. The specific indications for endoscopy will not be discussed in this article, although, in general, clinicians may wish to rule out malignancies or other noninfectious causes of the patient’s symptoms.

However, the sensitivity of this method is limited by a number of factors, including 1) the site of biopsy and the quantity of viable organisms, 2) ability to maintain viability of this fastidious bacterium during transport to the laboratory (<3 hours from collection to culture), and 3) unique culture conditions that are not routinely available in all clinical laboratories. For this assay, biopsy samples are submerged into the RUT solution, and if ammonia is produced, the pH will increase, leading to a color change that indirectly indicates the presence of H pylori. However, the sensitivity of this method is likewise limited by the site of biopsy and a lack of specificity as other nonpathogenic, curved bacteria may reside in the gastric mucosa. However, RT-PCR is not widely available in the clinical setting and is currently restricted to research laboratories. Of the 3 assays, the urea breath test (UBT) and the stool antigen test (SAT) are preferred over serologic evaluation to identify active disease.
For the UBT, the patient is asked to ingest a preparation containing 13C-labeled urea—a nonradioactive carbon isotope. Most notable is the decreased sensitivity of this assay in patients who have taken proton pump inhibitors (PPIs), bismuth-containing products, or antibiotics within 14 days prior to testing.
Additionally, unlike other noninvasive methods (ie, UBT and SAT), serologic profiles are not affected by prior use of PPIs, bismuth-containing compounds, or antibiotics, making serology an increasingly attractive method for immediate patient evaluation.
As a result of this meeting, Mayo Clinic providers will now order either the UBT or the SAT for patients with suspected H pylori infection.
Implementation of this practice change will lead to more accurate diagnosis of active H pylori infection and is expected to decrease the number of prescriptions for unnecessary antimicrobial agents. The infection is usually acquired during childhood and, if eradicated, is believed to rarely recur during adult life.
A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Multiple different testing methodologies are available commercially to detect H pylori infection. When symptoms are considered typical of H pylori disease, noninvasive testing for that infection will be initially performed. Due to the rigorous transport conditions, Mayo Medical Laboratories will currently only perform antimicrobial susceptibility testing on specimens submitted as H pylori isolates. Immunohistochemical stains have been developed to improve specificity, though cross-reactivity has been seen with other Helicobacter species (ie, Helicobacter heilmannii). If H pylori urease is present in the stomach, the urea is degraded to ammonia and labeled carbon dioxide (13CO2).
Additionally, the performance characteristics of these assays are poor, with clinical sensitivity and specificity parameters ranging from 76% to 85% and 79% to 90%, respectively.8,11 Finally, as antibodies to H pylori often remain for years following resolution of infection, serologic testing cannot be used to distinguish active from past infection or to document eradication of the organism following successful treatment.
This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Serologic evaluation for the presence of antibodies to H pylori is the most commonly ordered assay.
The advantages and limitations of the various testing methodologies will be reviewed within this article.

The labeled 13CO2 is exhaled through normal respiration and collected in a specialized bag.
For individuals <18 years, Mayo Medical Laboratories recommends that the stool antigen test (SAT) be offered instead.
The sample is subsequently analyzed on a spectrophotometer, which determines the level of 13CO2 present. Finally, the performance of this assay requires prolonged patient preparation (approximately 1 hour) and careful sample collection, which may be challenging if the collecting laboratory is unfamiliar with this test. This value is compared to a breath sample taken prior to ingestion of the labeled urea and a final result of positive or negative is determined (Figure 3). A review by de Boer and Tytgat clarifies and updates recommendations for treatment of patients with H.
In populations with a high incidence of ulcer disease, the authors recommend antibiotic treatment for all H.
These therapies are associated with cure rates of 80 to 90 percent based on intention to treat or completion of therapy, respectively. Therapies combining only a proton pump inhibitor and amoxicillin or clarithromycin are no longer regarded as effective. In metronidazole-sensitive strains, high cure rates are obtained after seven days, but 14 days of therapy are recommended to optimize eradication.
Although side effects are common, they are not generally severe and have not led to noncompliance in clinical trials. More recent triple therapies have replaced bismuth with a proton pump inhibitor and reduced the treatment period to seven days.
The optimal regimen for sensitive strains may be a twice-daily dosage of 20 mg of omeprazole (or equivalent), 1,000 mg of amoxicillin and 500 mg of clarithromycin. In areas with a high prevalence of resistant strains, therapy should continue for 10 to 14 days. An alternative triple therapy replaces the proton pump inhibitor with ranitidine bismuth citrate. The most effective quadruple regimens include tetracycline and metronidazole and are the most complicated to follow.
In metronidazole-sensitive strains, cure rates may be high after four days, but at least seven days of treatment are recommended.No ideal second-line treatment has been established if the initial therapy fails to eradicate the organism. Quadruple therapy has been successful after failure of regimens containing clarithromycin; results after regimens containing metronidazole were disappointing.

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