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Journal of Clinical Microbiology, July 2001, p. 2677-2680, Vol. 39, No. 7
0095-1137/01/$04.00+0 DOI: 10.1128/JCM.39.7.2677-2680.2001
Copyright © 2001, American Society for Microbiology. All rights reserved.
Increasing Multidrug Resistance in
Helicobacter pylori Strains Isolated from Children
and Adults in Mexico
Javier
Torres,1,*
Margarita
Camorlinga-Ponce,1
Guillermo
Pérez-Pérez,2
Armando
Madrazo-De la
Garza,3
Margarita
Dehesa,4
Gerardo
González-Valencia,1 and
Onofre
Muñoz1
Unidad de Investigación Médica en Enfermedades
Infecciosas,1 Departamento de
Gastroenterología, Hospital de
Pediatría,3 and
Departamento de Gastroenterología, Hospital de
Especialidades,4 Instituto Mexicano del
Seguro Social, Centro Médico Nacional Siglo XXI, Mexico City,
Mexico, and Division of Infectious Diseases, New York
University, New York, New York2
Received 22 December 2000/Returned for modification 14 March
2001/Accepted 30 April 2001
 |
ABSTRACT |
The susceptibilities to three antimicrobials of 195 Helicobacter pylori strains isolated from Mexican
patients is reported; 80% of the strains were resistant to
metronidazole, 24% were resistant to clarithromycin, and 18%
presented a transient resistance to amoxicillin. Resistance to two or
more antimicrobials increased significantly from 1995 to 1997.
| |
TEXT |
Eradication of
Helicobacter pylori infection is the most effective means to
cure peptic ulcer diseases and prevent possible recurrent episodes. The
most common treatment regimens include a proton pump inhibitor plus two
of the following antimicrobial agents: amoxicillin; clarithromycin; or
metronidazole or tetracycline. H. pylori resistance to
metronidazole and clarithromycin has increased worldwide (5,
15). Resistance to amoxicillin has been reported (10); however, this phenomenon is rare and unstable
(2).
Indications for treatment have been extended (3), and with
a more extended use of antibiotics, the probability of selection of
resistant strains increases.
We report here our findings on antimicrobial susceptibility patterns
among H. pylori strains isolated from children and adults during a 3-year period in Mexico.
Strains.
One hundred ninety-five H. pylori strains
isolated during the period from 1995 to 1997 were studied: 51 strains
were isolated from children (mean age, 11 ± 4 years) with
nonulcer dyspepsia (23 males and 28 females), whereas 144 strains were
isolated from adults (mean age, 52 ± 17 years), 48 with nonulcer
dyspepsia and 96 with peptic ulcers (93 males and 51 females). All
patients were seen at the Centro Médico Nacional Siglo XXI,
Instituto Mexicano del Seguro Social, in Mexico City, Mexico, and had
no history of eradication treatment. Organisms were recovered from antrum and corpus gastric biopsies and identified by morphology and
biochemical tests. Organisms were stored at 
70°C in 20%
glycerol-brain hearth infusion broth until tested.
Antimicrobial susceptibility assay.
Susceptibility to
amoxicillin, clarithromycin, and metronidazole was determined by the
Epsilometer test (E test; AB Biodisk, Solna, Sweden) (4).
H. pylori isolates were grown for 2 days on Columbia blood
agar plates; growth was suspended in Columbia broth to achieve a
McFarland opacity of 3 and spread on blood agar plates. The
antimicrobial drug strip was placed on the plate and incubated at
37°C for 72 h in an incubator with a 9%
CO2 atmosphere (Nuare, Plymouth, Minn.). The MIC
was defined by the point of intersection of the inhibitory zone with
the strip (4). To confirm results, each strain was tested
at least twice. The cutoff values for susceptibility were 8 µg/ml for
metronidazole, 4 µg/ml for amoxicillin, and 2 µg/ml for
clarithromycin (1, 10).
The susceptibility pattern obtained for the H. pylori
isolates is described in Table 1. The
rate of resistance to metronidazole was high (76.9%); resistance to
clarithromycin was moderate (24%). Resistance to amoxicillin was
observed in 18.5% of the isolates; however, resistance disappeared
after a single passage or after freezing the strains. In contrast,
resistance to clarithromycin and metronidazole remained unchanged after
passage or freezing. Of interest, 30.7% of isolates were
multiresistant, 17.9% to metronidazole and clarithromycin and 12.8%
to metronidazole and amoxicillin; 8.7% were resistant to all three
antibiotics tested. The distribution of MICs of the three antibiotics
for the 110 H. pylori strains isolated during 1997 is
presented in Fig. 1.
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FIG. 1.
Distribution of metronidazole, clarithromycin, and
amoxicillin MICs for 110 H. pylori strains isolated
during 1997.
|
|
The yearly rate of resistance during the period from 1995 to 1997 was
studied (Fig.
2). Resistance to
metronidazole was similar
throughout the 3 years; in contrast,
resistance to amoxicillin
and clarithromycin increased significantly
during the period of
study (Fig.
2a). Resistance to clarithromycin
increased from 10%
in 1995 to 27% in 1997, whereas resistance to
amoxicillin increased
from 13% in 1995 to 26% in 1997. Multidrug
resistance also increased
during this period (Fig.
2b); the rising
trend was significant
for resistance to metronidazole and
clarithromycin (
2 for linear trend = 8.073;
P = 0.004) as well as for resistance
to all
three antibiotics tested (
2 = 5.94;
P = 0.01). There was no difference in the rate of
resistance
to any of the three antibiotics tested when we compared
children
versus adults, men versus women, or ulcer disease isolates
versus
nonulcer dyspepsia isolates.
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FIG. 2.
Prevalence of H. pylori strains resistant
to amoxicillin, clarithromycin, and metronidazole isolated in Mexico
City during the period from 1995 to 1997. The numbers of strains
studied were 30 in 1995, 43 in 1996, and 110 in 1997. (a) Resistance to
amoxicillin or to clarithromycin; (b) resistance to two or three of the
antibiotics tested. The trend was significant for metronidazole and
clarithromycin (P = 0.004) and for the three
antibiotics (P = 0.01).
|
|
In this study we report the susceptibility of
H. pylori
strains from Mexico, a country with a high prevalence of infection
(
13), to the most commonly used antibiotics. A high rate
of
resistance to metronidazole was found consistently throughout
the 3 years of the study; these results are similar to frequencies
reported
for other developing countries (
9). In Mexico,
metronidazole
has commonly been used to treat diarrheal diseases for
many years
(
12); this is probably the cause of the high
rate of resistance
to this antibiotic. We could not demonstrate higher
metronidazole
resistance in females, despite the fact that gender has
been suggested
to be a risk factor for resistance to metronidazole,
probably
because of its use in the treatment of gynecologic infections
(
14). The value of the E test for testing susceptibility
to
metronidazole has been questioned recently (
11);
however, when
assay conditions are carefully controlled, results are
comparable
to those of agar dilution and disk diffusion (
8,
14). We
found moderate resistance to clarithromycin that
increased yearly.
Previous reports have suggested that the rate of
resistance to
clarithromycin is higher in strains isolated from
children than
in strains from adults (
7); however, we
found no difference
between the two
groups.
Recent reports have documented the existence of strains with resistance
to amoxicillin, although in most cases this resistance
was demonstrated
to be transitory (
2). In isolates from our
community, a
moderate prevalence of amoxicillin resistance was
observed;
nevertheless, this was unstable in all
cases.
Few studies have reported the rate of multidrug resistance in
H. pylori isolates. In this study, we document resistance to
at least
two antimicrobial agents in 30% of the isolates. A high
rate of
resistance to both metronidazole and clarithromycin (18%)
was found;
resistance to either of these two antimicrobials is
a risk factor for
treatment failure (
5). We are concerned that
resistance to
both clarithromycin and amoxicillin is continuously
increasing in our
community; in 1997 the rate of resistance to
either drug was over 25%,
suggesting that eventually these antimicrobials
will lose their
efficacy against
H. pylori infections. Resistance
to all
three antimicrobial drugs tested rose from 4% in 1995 to
12% in 1997. These results stress the need for alternative therapies.
Clinicians in
our community at present are recommending the use
of furazolidone and
tetracycline as alternatives; the use of these
antibiotics in
combination with ranitidine bismuth citrate has
been shown to be
effective and inexpensive in other communities
(
6).
In conclusion, we documented a high rate of resistance to metronidazole
and a rising resistance to both clarithromycin and
amoxicillin in our
community. It is of concern to us that multidrug
resistance to these
antimicrobial agents is also rising
significantly.
| |
ACKNOWLEDGMENTS |
This project was supported by CONACYT (grant 28040 M),
BykGulden-México, and the Coordinación de
Investigación, Instituto Mexicano del Seguro Social,
México.
| |
FOOTNOTES |
*
Corresponding author. Mailing address: Prol. Av.
Centenario 1707-39, Bosques de Tarango, México, D.F., CP 01580, México. Phone: 52 5 627-6940. Fax: 52 5 627-6949. E-mail:
jtorresl{at}axtel.net.
| |
REFERENCES |
| 1.
|
DeLoney, C. R., and N. L. Schiller.
2000.
Characterization of an in vitro-selected amoxicillin-resistant strain of Helicobacter pylori.
Antimicrob. Agents Chemother.
44:3368-3373[Abstract/Free Full Text].
|
| 2.
|
Dore, M. P.,
G. Realdi,
I. Mura,
M. S. Ostato,
D. Y. Graham, and A. R. Sepulveda.
1997.
Amoxicillin-resistant strains of H. pylori undergo reversible loss of resistance after storage.
Gut
41(Suppl. 1):A8.
|
| 3.
|
The European Helicobacter pylori Study Group.
1997.
Current European concepts in the management of Helicobacter pylori infection. The Maastricht Consensus Report.
Gut
41:8-13[Abstract/Free Full Text].
|
| 4.
|
Glupczynski, Y.,
M. Labbe,
H. Willy, and E. C. Yourassowsky.
1991.
Evaluation of the E test for quantitative antimicrobial susceptibility testing of Helicobacter pylori.
J. Clin. Microbiol.
29:2072-2075[Abstract/Free Full Text].
|
| 5.
|
Graham, D. Y.
1998.
Antibiotic resistance in Helicobacter pylori: implications for therapy.
Gastroenterology
115:1272-1277[CrossRef][Medline].
|
| 6.
|
Graham, D. Y.,
M. S. Osato,
J. Hoffman,
A. R. Opekun,
S. Y. Anderson, and H. M. T. El-Zimaity.
2000.
Furazolidone combination therapies for Helicobacter pylori infection in the United States.
Aliment. Pharmacol. Ther.
14:211-215[CrossRef][Medline].
|
| 7.
|
Jesch, I.,
A. Kindermann,
S. Krauss-Etschmann,
I. Autenrieth,
N. Lehn, and S. Koletzko.
1999.
Prevalence of clarithromycin-resistant H. pylori-strains in children: effect of therapy.
Gut
45(Suppl. III):A93.
|
| 8.
|
Kalach, N.,
M. Bergeret,
P. H. Benhamou,
C. Dupont, and J. Raymond.
2001.
High levels of resistance to metronidazole and clarithromycin in Helicobacter pylori strains in children.
J. Clin. Microbiol.
39:394-397[Abstract/Free Full Text].
|
| 9.
|
Mégraud, F.
1998.
Epidemiology and mechanism of antibiotic resistance in Helicobacter pylori.
Gastroenterology
115:1278-1282[CrossRef][Medline].
|
| 10.
|
Mendonca, S.,
C. Ecclissato,
M. S. Sartori,
A. P. Ortiz,
R. Aparecida, and M. D. Pedrazzoli.
2000.
Prevalence of Helicobacter pylori resistance to metronidazole, clarithromycin, amoxicillin, tetracycline, and furazolidone in Brazil.
Helicobacter
5:79-83[CrossRef][Medline].
|
| 11.
|
Piccolomini, R.,
G. D. Bonaventura,
G. Catamo,
F. Carbone, and M. Neri.
1997.
Comparative evaluation of the E test, agar dilution, and broth microdilution for testing susceptibilities of Helicobacter pylori strains to 20 antimicrobial agents.
Ann. Intern. Med.
109:11-17.
|
| 12.
|
Torres, J.,
S. Gonzalez-Arroyo,
R. Pérez, and O. Muñoz.
1995.
Inappropriate treatment in children with bloody diarrhea: clinical and microbiological studies.
Arch. Med. Res.
26:23-29[Medline].
|
| 13.
|
Torres, J.,
Y. Leal-Herrera,
G. I. Pérez-Pérez,
A. Gómez,
M. Camorlinga-Ponce,
R. Cedillo-Ribera,
R. Tapia-Conyer, and O. Muñoz.
1998.
A community-based seroepidemiological study of Helicobacter pylori infection in Mexico.
J. Infect. Dis.
178:1089-1094[Medline].
|
| 14.
|
van der Wouden, E. J.,
J. C. Thijs,
A. A. van Zwet, and J. H. Kleibeuker.
2000.
Nitroimidazole resistance in Helicobacter pylori.
Aliment. Pharmacol. Ther.
14:7-14[Medline].
|
| 15.
|
van der Wouden, E. J.,
A. A. van Zwet,
J. C. Thijs,
G. D. C. Vosmaer, and J. H. Kleibeuker.
1997.
Rapid increase in the prevalence of metronidazole-resistant Helicobacter pylori in The Netherlands.
Emerg. Infect. Dis.
3:385-389[Medline].
|
Journal of Clinical Microbiology, July 2001, p. 2677-2680, Vol. 39, No. 7
0095-1137/01/$04.00+0 DOI: 10.1128/JCM.39.7.2677-2680.2001
Copyright © 2001, American Society for Microbiology. All rights reserved.
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