BACKGROUND: Antimicrobial resistance of H. pylori can lead to treatment failure. Importantly, several studies have reported on heteroresistance, i.e. the presence of resistant and susceptible H. pylori populations in the same sample and/or a difference in the susceptibility patterns between biopsy samples. This meta-analysis aims to provide comprehensive data on the prevalence of metronidazole and clarithromycin heteroresistance and the approaches to their detection. MATERIAL AND METHODS: A systematic review was performed after the search of MEDLINE, Scopus and Web of Science. The study outcomes were the weighted pooled prevalence of heteroresistance to clarithromycin and metronidazole in H. pylori positive samples and/or isolates with a subanalysis by continent. RESULTS: A total of 22 studies that had investigated 3852 H. pylori positive patients were included in the meta-analysis. Heteroresistance to clarithromycin was reported in 20 studies, with a weighted pooled prevalence of 6.8% (95% CI 5.1-8.6; 3654 H. pylori positive patients; the substantial heterogeneity I2 = 55.6%). Heteroresistance to metronidazole was reported in 12 studies, with a weighted pooled prevalence of 13.8% (95% CI 8.9-18.6; 1670 H. pylori positive patients; the substantial heterogeneity I2 = 60.9%). The weighted pooled prevalence of clarithromycin heteroresistance was similar in Asia and Europe (p = 0.174584), however, metronidazole heteroresistance was detected more often in Europe (p < 0.00001). Clarithromycin heteroresistance was detected more often by phenotype rather than by using genotyping methods (12 vs 8 studies), whereas heteroresistance to metronidazole was detected only by phenotype. CONCLUSION: The prevalence of heteroresistance to clarithromycin and/or metronidazole is not negligible and can be detected in approximately 7 and 14% of H. pylori positive samples, respectively. These findings highlight the need to raise the awareness of gastroenterologists and microbiologists to the heteroresistance to clarithromycin and metronidazole in patients with a H. pylori infection.

Clinical Microbiology Research Centre Ilam University of Medical Sciences Ilam Iran

Department of Medical Microbiology Charles University 2nd Faculty of Medicine and Motol University Hospital Prague Czech Republic

Department of Microbiology Faculty of Medicine Ilam University of Medical Sciences Ilam Iran

Golestan Research Center of Gastroenterology and Hepatology Golestan University of Medical Sciences Gorgan Iran

Laboratory Sciences Research Centre Golestan University of Medical Sciences Gorgan Iran

Non Communicable Diseases Research Centre Ilam University of Medical Sciences Ilam Iran

Zobrazit více v PubMed

Calvet X, Ramírez Lázaro MJ, Lehours P, Mégraud F. Diagnosis and epidemiology of Helicobacter pylori infection. Helicobacter. 2013;18:5–11. doi: 10.1111/hel.12071. PubMed DOI

Crowe SE. Helicobacter pylori infection. N Engl J Med. 2019;380(12):1158–1165. doi: 10.1056/NEJMcp1710945. PubMed DOI

IARC Working Group: Schistosomes liver flukes and Helicobacter pylori IARC working group on the evaluation of carcinogenic risks to humans Lyon, 7–14 June 1994. IARC Monogr Eval Carcinog Risks Hum. 1994;61:1–241. PubMed PMC

Fallone CA, Moss SF, Malfertheiner P. Reconciliation of recent Helicobacter pylori treatment guidelines in a time of increasing resistance to antibiotics. Gastroenterology. 2019;157(1):44–53. doi: 10.1053/j.gastro.2019.04.011. PubMed DOI

Blanchard TG, Nedrud JG. Laboratory maintenance of Helicobacter species. Curr Protoc Microbiol. 2006 doi: 10.1002/9780471729259.mc08b01s00. PubMed DOI PMC

Saniee P, Shahreza S, Siavoshi F. Negative effect of proton-pump inhibitors (PPIs) on Helicobacter pylori growth, morphology, and urease test and recovery after ppi removal–an in vitro study. Helicobacter. 2016;21(2):143–152. doi: 10.1111/hel.12246. PubMed DOI

Smith SM, O'Morain C, McNamara D. Antimicrobial susceptibility testing for Helicobacter pylori in times of increasing antibiotic resistance. World J Gastroenterol. 2014;20(29):9912–9921. doi: 10.3748/wjg.v20.i29.9912. PubMed DOI PMC

Matteo MJ, Pérez CV, Domingo MR, Olmos M, Sanchez C, Catalano M. DNA sequence analysis of rdxA and frxA from paired metronidazole-sensitive and-resistant Helicobacter pylori isolates obtained from patients with heteroresistance. Int J Antimicrob Agents. 2006;27(2):152–158. doi: 10.1016/j.ijantimicag.2005.09.019. PubMed DOI

Nishizawa T, Suzuki H. Mechanisms of Helicobacter pylori antibiotic resistance and molecular testing. Front Mol Biosci. 2014;1:19. doi: 10.3389/fmolb.2014.00019. PubMed DOI PMC

Bina JE, Alm RA, Uria-Nickelsen M, Thomas SR, Trust TJ, Hancock RE. Helicobacter pylori uptake and efflux: basis for intrinsic susceptibility to antibiotics in vitro. Antimicrob Agents Chemother. 2000;44(2):248–254. doi: 10.1128/AAC.44.2.248-254.2000. PubMed DOI PMC

Tshibangu-Kabamba E, Yamaoka Y. Helicobacter pylori infection and antibiotic resistance - from biology to clinical implications. Nat Rev Gastroenterol Hepatol. 2021;18(9):613–629. doi: 10.1038/s41575-021-00449-x. PubMed DOI

Kocsmár É, Kocsmár I, Buzás GM, Szirtes I, Wacha J, Takáts A, Hritz I, Schaff Z, Rugge M, Fassan M, Kiss A, Lotz G. Helicobacter pylori heteroresistance to clarithromycin in adults-new data by in situ detection and improved concept. Helicobacter. 2020;25(1):e12670. doi: 10.1111/hel.12670. PubMed DOI

Kim JJ, Kim JG, Kwon DH. Mixed-infection of antibiotic susceptible and resistant Helicobacter pylori isolates in a single patient and underestimation of antimicrobial susceptibility testing. Helicobacter. 2003;8(3):202–206. doi: 10.1046/j.1523-5378.2003.00145.x. PubMed DOI

Kao CY, Lee AY, Huang AH, Song PY, Yang YJ, Sheu SM, Chang WL, Sheu BS, Wu JJ. Heteroresistance of Helicobacter pylori from the same patient prior to antibiotic treatment. Infect Genet Evol. 2014;23:196–202. doi: 10.1016/j.meegid.2014.02.009. PubMed DOI

Matteo MJ, Pérez CV, Domingo MR, Olmos M, Sanchez C, Catalano M. DNA sequence analysis of rdxA and frxA from paired metronidazole-sensitive and -resistant Helicobacter pylori isolates obtained from patients with heteroresistance. Int J Antimicrob Agents. 2006;27(2):152–158. doi: 10.1016/j.ijantimicag.2005.09.019. PubMed DOI

Farzi N, Behzad C, Hasani Z, Alebouyeh M, Zojaji H, Zali MR. Characterization of clarithromycin heteroresistance among Helicobacter pylori strains isolated from the antrum and corpus of the stomach. Folia Microbiol. 2019;64(2):143–151. doi: 10.1007/s12223-018-0637-9. PubMed DOI

Arévalo-Jaimes BV, Rojas-Rengifo DF, Jaramillo CA, de Molano BM, Vera-Chamorro JF, Del Pilar DM. Genotypic determination of resistance and heteroresistance to clarithromycin in Helicobacter pylori isolates from antrum and corpus of colombian symptomatic patients. BMC Infect Dis. 2019;19(1):546. doi: 10.1186/s12879-019-4178-x. PubMed DOI PMC

Neyeloff JL, Fuchs SC, Moreira LB. Meta-analyses and forest plots using a microsoft excel spreadsheet: step-by-step guide focusing on descriptive data analysis. BMC Res Notes. 2012;5:52. doi: 10.1186/1756-0500-5-52. PubMed DOI PMC

Güven B, Gülerman F, Kaçmaz B. Helicobacter pylori resistance to clarithromycin and fluoroquinolones in a pediatric population in Turkey: a cross-sectional study. Helicobacter. 2019;24(3):e12581. doi: 10.1111/hel.12581. PubMed DOI

Sun L, Talarico S, Yao L, He L, Self S, You Y, Zhang H, Zhang Y, Guo Y, Liu G, Salama NR, Zhang J. Droplet digital pcr-based detection of clarithromycin resistance in Helicobacter pylori isolates reveals frequent heteroresistance. J Clin Microbiol. 2018;56(9):e00019–e118. doi: 10.1128/JCM.00019-18. PubMed DOI PMC

Mascellino MT, Oliva A, De Angelis M, Pontone S, Porowska B. Helicobacter pylori infection: antibiotic resistance and eradication rate in patients with gastritis showing previous treatment failures. New Microbiol. 2018;41(4):306–309. PubMed

Aguilera-Correa JJ, Urruzuno P, Barrio J, Martinez MJ, Agudo S, Somodevilla A, Llorca L, Alarcón T. Detection of Helicobacter pylori and the genotypes of resistance to clarithromycin and the heterogeneous genotype to this antibiotic in biopsies obtained from symptomatic children. Diagn Microbiol Infect Dis. 2017;87(2):150–153. doi: 10.1016/j.diagmicrobio.2016.03.001. PubMed DOI

Ben Mansour K, Fendri C, Battikh H, Garnier M, Zribi M, Jlizi A, Burucoa C. Multiple and mixed Helicobacter pylori infections: comparison of two epidemiological situations in Tunisia and France. Infect Genet Evol. 2016;37:43–48. doi: 10.1016/j.meegid.2015.10.028. PubMed DOI

Navarro-Jarabo JM, Fernández-Sánchez F, Fernández-Moreno N, Hervas-Molina AJ, Casado-Caballero F, Puente-Gutierrez JJ, Pallares-Manrique H, Rodríguez-Ramos C, Fernández-Gutierrez C, Pérez-Aisa A, Rivas-Ruiz F, Montiel Q-G. Prevalence of primary resistance of Helicobacter pylori to clarithromycin and levofloxacin in Southern Spain. Digestion. 2015;92(2):78–82. doi: 10.1159/000435949. PubMed DOI

Selgrad M, Tammer I, Langner C, Bornschein J, Meißle J, Kandulski A, Varbanova M, Wex T, Schlüter D, Malfertheiner P. Different antibiotic susceptibility between antrum and corpus of the stomach, a possible reason for treatment failure of Helicobacter pylori infection. World J Gastroenterol. 2014;20(43):16245–16251. doi: 10.3748/wjg.v20.i43.16245. PubMed DOI PMC

Ayala G, Galván-Portillo M, Chihu L, Fierros G, Sánchez A, Carrillo B, Román A, López-Carrillo L, Silva-Sánchez J, Study Group Resistance to antibiotics and characterization of Helicobacter pylori strains isolated from antrum and body from adults in Mexico. Microb Drug Resist. 2011;17(2):149–155. doi: 10.1089/mdr.2010.0154. PubMed DOI

Marzio L, Cellini L, Amitrano M, Grande R, Serio M, Cappello G, Grossi L. Helicobacter pylori isolates from the proximal and distal stomach of patients never treated and already treated show genetic variability and discordant antibiotic resistance. Eur J Gastroenterol Hepatol. 2011;23(6):467–472. doi: 10.1097/MEG.0b013e328345d40f. PubMed DOI

Norazah A, Rasinah WZ, Zaili Z, Aminuddin A, Ramelah M. Analysis of PCR-RAPD DNA and antibiotic susceptibility profiles of the antrum and corpus isolates of Helicobacter pylori from Malaysian patients. Malays J Pathol. 2009;31(1):29–34. PubMed

Raymond J, Nguyen B, Bergeret M, Dupont C, Kalach N. Heterogeneous susceptibility to metronidazole and clarithromycin of Helicobacter pylori isolates from a single biopsy in adults is confirmed in children. Int J Antimicrob Agents. 2005;26(4):272–278. doi: 10.1016/j.ijantimicag.2005.07.007. PubMed DOI

Lee YC, Lee SY, Pyo JH, Kwon DH, Rhee JC, Kim JJ. Isogenic variation of Helicobacter pylori strain resulting in heteroresistant antibacterial phenotypes in a single host in vivo. Helicobacter. 2005;10(3):240–248. doi: 10.1111/j.1523-5378.2005.00316.x. PubMed DOI

Rimbara E, Noguchi N, Tanabe M, Kawai T, Matsumoto Y, Sasatsu M. Susceptibilities to clarithromycin, amoxycillin and metronidazole of Helicobacter pylori isolates from the antrum and corpus in Tokyo, Japan, 1995–2001. Clin Microbiol Infect. 2005;11(4):307–311. doi: 10.1111/j.1469-0691.2005.01099.x. PubMed DOI

Masuda H, Hiyama T, Yoshihara M, Tanaka S, Shimamoto F, Haruma K, Chayama K. Necessity of multiple gastric biopsies from different sites for detection of clarithromycin-resistant Helicobacter pylori strains. Scand J Gastroenterol. 2003;38(9):942–946. doi: 10.1080/00365520310004731. PubMed DOI

van der Ende A, van Doorn LJ, Rooijakkers S, Feller M, Tytgat GN, Dankert J. Clarithromycin-susceptible and -resistant Helicobacter pylori isolates with identical randomly amplified polymorphic DNA-PCR genotypes cultured from single gastric biopsy specimens prior to antibiotic therapy. J Clin Microbiol. 2001;39(7):2648–2651. doi: 10.1128/JCM.39.7.2648-2651.2001. PubMed DOI PMC

Weel JF, van der Hulst RW, Gerrits Y, Tytgat GN, van der Ende A, Dankert J. Heterogeneity in susceptibility to metronidazole among Helicobacter pylori isolates from patients with gastritis or peptic ulcer disease. J Clin Microbiol. 1996;34(9):2158–2162. doi: 10.1128/JCM.34.9.2158-2162.1996. PubMed DOI PMC

Malfertheiner P, Megraud F, O'Morain CA, Gisbert JP, Kuipers EJ, Axon AT, Bazzoli F, Gasbarrini A, Atherton J, Graham DY, Hunt R, Moayyedi P, Rokkas T, Rugge M, Selgrad M, Suerbaum S, Sugano K, El-Omar EM, European Helicobacter and Microbiota Study Group and consensus panel Management of Helicobacter pylori infection-the Maastricht V/Florence consensus report. Gut. 2017;66(1):6–30. doi: 10.1136/gutjnl-2016-312288. PubMed DOI

Savoldi A, Carrara E, Graham DY, Conti M, Tacconelli E. Prevalence of antibiotic resistance in Helicobacter pylori: a systematic review and meta-analysis in world health organization regions. Gastroenterology. 2018;155(5):1372–1382.e17. doi: 10.1053/j.gastro.2018.07.007. PubMed DOI PMC

Miftahussurur M, Fauzia KA, Nusi IA, Setiawan PB, Syam AF, Waskito LA, Doohan D, Ratnasari N, Khomsan A, Adnyana IK, Akada J, Yamaoka Y. E-test versus agar dilution for antibiotic susceptibility testing of Helicobacter pylori: a comparison study. BMC Res Notes. 2020;13(1):22. doi: 10.1186/s13104-019-4877-9. PubMed DOI PMC

Rizvanov AA, Haertlé T, Bogomolnaya L, Talebi Bezmin Abadi A. Helicobacter pylori and its antibiotic heteroresistance: a neglected issue in published guidelines. Front Microbiol. 2019;10:1796. doi: 10.3389/fmicb.2019.01796. PubMed DOI PMC