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Department of Health and Social Services
Division of Public Health
Helicobacter pylori Antimicrobial Resistance and Treatment for Alaska Native People
high prevalence of infection, reinfection, and treatment failure Helicobacter pylori bacterial infection predisposes individuals of H. pylori in Alaska Native people warrants H. pylori to gastric and duodenal ulcers, chronic active gastritis, screening and treatment guidelines specific to this population mucosal-associated lymphoid tissue (MALT) lymphoma, and gastric adenocarcinoma.1 Infection usually occurs during Box. H. pylori Screening and Treatment Guidelines for
Alaska Native Patients
transmission, more commonly in crowded household settings.1 With a seroprevalence of 75% (range: 61–84%, by region), Test and treat H. pylori infection in persons with: 1) Alaska Native people experience higher rates of H. pylori duodenal or gastric ulcers;6 2) MALT lymphoma; 3) infection and stomach cancer than non-Native Alaskans.2,3 severe gastritis (not NSAID or alcohol-related), especially Antimicrobial resistance is more common in H. pylori isolates in those patients with unexplained anemia. from Alaska Native people than in other U.S. populations,4 Do not test for H. pylori in routine dyspepsia evaluations
and contributes to relatively high treatment failure rates (26% because most patients will have positive serologic results in one study).5 Understanding antimicrobial resistance patterns can guide therapy and increase H. pylori treatment success in Treat H. pylori infection with an FDA-approved regimen accounting for local antimicrobial resistance patterns. In Alaska Native patients, metronidazole-based quadruple therapy regimens (usually containing tetracycline, The Arctic Investigations Program (AIP), Centers for Disease bismuth, and a proton pump inhibitor [PPI]) have shown Control and Prevention (CDC) H. pylori Sentinel Surveillance System cultures H. pylori from endoscopic biopsy tissue Test individuals treated for H. pylori infection 2 months submitted from five hospitals that provide care to Alaska Native people across five regions of Alaska. The AIP Consider other therapies (e.g., PPI, H2 blockers, or pro- laboratory conducts minimum inhibitory concentration testing kinetic drugs) instead of H. pylori treatment in people of isolates for antibiotics commonly used to treat H. pylori with: 1) dyspepsia without anemia; 2) mild to moderate infection (i.e., metronidazole, clarithromycin, levofloxacin, gastritis, esophagitis, or clear reflux symptoms; 3) poor Of the 1,256 Alaska Native stomach biopsy samples received drug; FDA=Food and Drug Administration) from January 2000 through December 2009, 45.1% Recommendations
(566/1,256) were culture-positive for H. pylori. Among 1. Providers should follow the H. pylori screening and patients with H. pylori-positive cultures, the proportions of treatment guidelines for Alaska Native patients (Box). 2. Test for H. pylori cure with urea breath, fecal antigen, or clarithromycin, levofloxacin, and amoxicillin were 41.7% endoscopic tests 2 months after completion of therapy. (235/564), 29.3% (165/564), 19.7% (37/188) and 1.8% 3. If at a participating hospital, send endoscopic gastric (10/564), respectively. We found no tetracycline-resistant biopsy specimens to the AIP laboratory for H. pylori and isolates or statistically significant trends in antimicrobial resistance over time. Levofloxacin resistance was more common in patients living in Anchorage/Mat-Su than other References
regions (29.1% vs. 15.8%, P=0.04; Table). Clarithromycin and Kusters JG, van Vliet AH, Kuipers EJ. Pathogenesis of Helicobacter metronidazole resistance were more frequent in females than pylori infection. Clin Microbiol Rev 2006;3:449-90. Parkinson AJ, Gold BD, Bulkow L, et al. High prevalence of males (36.4% vs. 22.6%, P=0.003 and 52.2% vs. 31.9%, Helicobacter pylori in the Alaska Native population and association with low serum ferritin levels in young adults. Clin Diagn Lab Immunol Discussion
Wiggins CL, Perdue DG, Henderson JA, et al. Gastric cancer among Antimicrobial resistance is common among H. pylori isolates American Indians and Alaska Natives in the United States, 1999-2004. cultured from Alaska Native patients. Although surveillance Cancer 2008;113(5 Suppl):1225-33. Bruce MG, Bruden DL, McMahon BJ, et al. Alaska sentinel surveillance has shown that metronidazole resistance is common, treatment for antimicrobial resistance in Helicobacter pylori isolates from Alaska failure occurred more often in patients with clarithromycin- Native persons, 1999-2003. Helicobacter 2006;11(6):581-8. resistant isolates who received clarithromycin-based regimens McMahon BJ, Hennessy TW, Bensler JM, et al. The relationship among (10/13) than patients with metronidazole-resistant isolates who previous antimicrobial use, antimicrobial resistance, and treatment outcomes for Helicobacter pylori infections. Ann Intern Med received metronidazole-based regimens (2/18).5 When treating an Alaska Native patient for H. pylori infection, a NIH Consensus Development Conference. Helicobacter pylori in peptic metronidazole-based regimen should be first line therapy. The ulcer disease. JAMA 1994;272:65-9. Table. Regional H. pylori Prevalence and Antimicrobial Susceptibility among Alaska Native Persons (N=1,256), 2000–2009
(Contributed by James W. Keck, MD, MPH, Michael Bruce, MD, MPH, and Brian McMahon, MD, Arctic Investigations Program, CDC.)


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