Microsoft word - report workshop4 copen 2005.doc

Workshop Summaries Copenhagen
XVIIIth International Workshop on
Gastrointestinal Pathology and Helicobacter
Workshop 4: Clinical experiences
Chairpersons: C. O’Morain, Dublin, Ireland & P. Bytzer, Copenhagen, Denmark.
Reporter: P. Bytzer, Copenhagen, Denmark.

In the workshop, six scientists gave short presentations on various aspects of Helicobacter pylori-related clinical disorders, ranging from long term outcome after eradication therapy for MALT lymphoma to surveillance of antibiotic resistance of the organism. Jung et al. (11.02) from Seoul, Korea, reported on the outcome of 97 H. pylori-infected patients with MALT lymphoma, who had been treated with eradication therapy between 1996 and 2003. Median follow-up time was 29 months. Eradication and tumour response were followed by endoscopy and CT scans. Ninety percent of the patients were in complete remission after 12 months but lymphoma recurred in 12.7% (nine patients). H. pylori re-infection was the only significant factor predicting relapse of the lymphoma. The authors recommended systematic follow up by endoscopy to evaluate H. pylori status and recurrence after eradication therapy for low grade lymphoma. Eradication of H. pylori is strongly recommended in patients with gastric cancer. In patients who are candidates for surgical resection, the gastric remnant is at increased risk of a new cancer due to persistent H. pylori infection. Song et al. (11.04) from Korea had randomised patients with distal gastric cancer and H. pylori infection to either pre-operative or post-operative eradication therapy. All patients had subtotal gastrectomy performed (Billroth I in 92 patients and Billroth II in 38 patients). Only patients with pre-operative clinical cancer stages IA, IB, II, or IIIA were included. The pre-operative group received eradication therapy before surgery and the post-operative group received the treatment 2 to 4 weeks after surgery. The eradication regimen consisted of twice daily dosing of rabeprazole (10 mg), clarithromycin (500 mg) and amoxicillin (1000 mg), for 7 days. At 12 weeks after the operation, four biopsy specimens for histology and one specimen for rapid urease test were obtained and a urea breath test was performed. All test results had to be negative for the eradication therapy to be considered successful. A total of 130 patients, 65 in each group, were in the ITT analysis and 124 patients were analyzed per protocol. Eradication rates in the pre-operative group were 80.0% (ITT analysis) and 82.5% (per protocol). Corresponding figures for the post-operative group were 73.8% and 78.7%, respectively. These differences were not statistically significant. The type of operation had no impact on eradication rates. H. pylori eradication rates above 95% should be the goal when choosing eradication regimes. Unfortunately, eradication rates as low as 80% are often reported, even when recommended regimes are used. A systematic review and meta-analysis, reported by Gisbert et al. (11.06) from Madrid, Spain, analysed a total of 30 published trials comparing first line eradication rates using two antibiotics with either a proton pump inhibitor (PPI) or bismuth citrate. The methodological quality of the trials were evaluated independently by two reviewers based on randomization, double blinding and description of drop-outs. Unfortunately, unpublished studies were not included in the meta-analysis. The analysis showed comparable eradication rates when PPIs and bismuth were combined with clarithromycin and amoxicillin, but if a clarithromycin - nitroimidazole regimen was used, significantly higher efficacy was observed with the bismuth combinations. Eradication therapies based on clarithromycin and amoxicillin or metronidazole are still recommended as first line choice by the Maastricht consensus conference. However, resistance problems are increasing and alternative regimens are required. Nista et al. (11.01) from Rome, Italy, presented the outcome of a randomized trial comparing eradication rates after 7 days PPI-based treatments with clarithromycin (500 mg bid) combined with either amoxicillin (1 g bid), metronidazole (500 mg bid) or levofloxacin (500 mg od). Each of the three arms in the trial had 100 infected subjects. H. pylori status was checked after 6 weeks using a breath test. The eradication rate analysed in the ITT group was 87% with the levofloxacin-based regimen, which was significantly higher compared to the standard therapies (75% and 72%, respectively). The prevalence of side-effects did not differ between the groups. A levofloxacin-clarithromycin-PPI triple therapy might be used as a relatively effective first-line regimen. More clinical experience with this combination from other geographic areas is warranted. Resistance to levofloxacin and ciprofloxacin was found in 16.8% of 488 H. pylori strains isolated in a Belgian study presented by Bogaerts et al. (13.01) from Mont-Godinne. Primary resistance was always associated with one or more mutations at position 87 and/or 91. A high proportion of these strains showed a heterogeneous susceptibility to fluoroquinolones. The type and the level of the mutations did not match with the level of resistance to the antibiotics. Antibiotic resistance is a key factor in the failure of eradication therapy. Variable resistance rates have been reported in different studies but direct comparisons can be difficult owing to lack of standardised methods. Few sentinel schemes exist that monitor trends in antibiotic resistance at the local, national or international level. Owen et al. (13.04) from London, U.K., reported data on the primary antibiotic resistance of H. pylori from two regions, an urban and a rural, over a 5-year period from 2000 to 2004. Susceptibilities to metronidazole, clarithromycin, amoxicillin and tetracycline were determined by disc diffusion and by E-test for 1024 isolates from dyspeptic patients. Metronidazole resistance rates varied between 29.6% and 33.6% and seemed to increase over time. Clarithromycin resistance was found in 8.6% to 12.6% of the isolates. A temporal trend for increasing resistance rates was observed in both regions. Only three cases of tetracycline resistance were detected and no isolates were resistant to amoxicillin. Higher rates of metronidazole and clarithromycin resistance were found in female patients.


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