- Email: [email protected]
Author reply: Comment to “Different Antibiotic No Culture Eradicating (DANCE) strategy: An easy way to manage H. pylori eradication”
Digestive and Liver Disease 45 (2013) 438–439
Contents lists available at SciVerse ScienceDirect
Digestive and Liver Disease journal homepage: www.elsevier.com/locate/dld
Correspondence Comment to: “Different Antibiotic No Culture Eradication (DANCE) of Helicobacter pylori: An easy way to manage H. pylori eradication” Dear Editor, Successful Helicobacter pylori eradication prevents the potentially problematic outcome of Helicobacter colonisation. Unfortunately the success rate of H. pylori therapy has been falling due to a worldwide increase in antibiotic resistance [1]. The paper by Roccarina et al. [2] proposes a novel approach on the treatment of H. pylori infections which they refer to as the ‘DANCE strategy’. Their strategy essentially obviates the need for endoscopy and microbiological culture as it proposes to prescribe antibiotics empirically in a stepwise manner. Although this may be effective for individual patients we feel that such a strategy is bound to induce antibiotic resistance, and thus will eventually be harmful to the community. Treatment of H. pylori needs multiple antibiotics, and eradication rates already decline if there is resistance against one of the antibiotics in such a combination therapy [1]. As such a patient is factually treated with monotherapy, the likelihood of selection of resistance against the other still active antibiotic(s) increases, and this potentially results in multi-drug resistant isolates [1,3]. We firmly believe that avoiding antibiotic susceptibility testing, as proposed in the DANCE strategy will facilitate emergence of antibiotic resistance. There are numerous examples of infections where exactly the same has happened, such as for instance tuberculosis and HIV [4]. As there are only a handful of oral antibiotics effective against Helicobacter and since combination of two or three antibiotics and an acid inhibitor is required, we should prevent losing these treatment options. This avoidable selection of (multi-drug) resistant isolates may not only harm the individual patient, but may also harm newly infected patients, as in other infections. Indeed endoscopy and subsequent culture and susceptibility testing are not always possible. Yet, there are reliable methods to accurately determine presence of H. pylori in faeces, saliva and blood, such as ELISA and direct PCR [5]. As the molecular mechanisms of resistance of H. pylori are known [5] determination of these genes with molecular tests based on H. pylori DNA in faeces seems feasible [6]. The costs of molecular tests have dropped significantly and are nowadays similar to costs of ELISA or cultures. Therefore, considering the global emergence of antibiotic resistance among H. pylori we feel that the DANCE strategy is potentially harmful and that our efforts should be directed towards antibiotic susceptibility guided treatment of H. pylori infection, where possible.
Conflict of interest statement None.
References [1] De Francesco V, Giorgio F, Hassan C, et al. Worldwide H. pylori antibiotic resistance: a systematic review. Journal of Gastrointestinal and Liver Disease 2010;19:409–14. [2] Roccarina D, Franceschi F, Zocco MA, et al. Different Antibiotic No Culture Eradicating (DANCE) strategy: an easy way to manage H. pylori eradication. Digestive and Liver Disease 2012;44:889–92. [3] Selgrad M, Bornschein J, Malfertheiner P. Guidelines for treatment of Helicobacter pylori in east and west. Expert Review of Anti-Infective Therapy 2011, http://dx.doi.org/10.1586/eri.11.80. [4] Pasipanodya JG, Gumbo T. A new evolutionary and pharmacokinetic– pharmacodynamic scenario for rapid emergence of resistance to single and multiple anti-tuberculosis drugs. Current Opinion in Pharmacology 2011;11:457–63. [5] Mégraud F, Lehours P. Helicobacter pylori detection and antimicrobial susceptibility testing. Clinical Microbiology Reviews 2007;20:280–322. [6] Makristathis A, Hirschl AM, Lehours P, et al. Diagnosis of Helicobacter pylori infection. Helicobacter 2004;9(Suppl. 1):7–14.
Amin Talebi Bezmin Abadi Marc J. Bonten Johannes Gerardus Kusters ∗ Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands ∗ Corresponding
author at: Department of Medical Microbiology, University Medical Center Utrecht, Heidelberglaan, 100, 3584 CX Utrecht, The Netherlands. Tel.: +31 88 7553687/7556524. E-mail addresses: [email protected], [email protected] (J.G. Kusters) 12 November 2012 Available online 29 January 2013
http://dx.doi.org/10.1016/j.dld.2012.12.015
Author reply: Comment to “Different Antibiotic No Culture Eradicating (DANCE) strategy: An easy way to manage H. pylori eradication” Dear Editor, We have read the letter by Amin Talebi Bezmin Abadi et al. [1] criticizing the use of the “Different Antibiotic No Culture Eradicating (DANCE)” strategy to eradicate Helicobacter pylori (H. pylori) [2]. We are perfectly aware that antibiotic resistance is an emerging issue nowadays, and that treating patients with multiple antibiotics “empirically” may contribute to inducing such resistances [3]. However, we believe that the authors may have misunderstood the original message provided by our paper. In fact, we are in favour of applying new techniques to detect antibiotic resistance before deciding the best eradication regimen. Nevertheless, although simple and not excessively expensive, this strategy may not universally
1590-8658/$36.00 © 2013 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
Correspondence / Digestive and Liver Disease 45 (2013) 438–439
applicable, especially for patients referred primarily to low-volume peripheral centres [4]. Only in those selected cases do we propose the DANCE strategy, which in contrast should be avoided in highly specialized centres. Conflict of interest statement We certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. References [1] Abadi ATB, Bonten MJ, Kusters JG. Comment to “Different Antibiotic No Culture Eradication (DANCE) of Helicobacter”. Digestive and Liver Disease; in press. [2] Roccarina D, Franceschi F, Zocco MA, et al. Different Antibiotic No Culture Eradicating (DANCE) strategy: an easy way to manage H. pylori eradication. Digestive and Liver Disease 2012;44:889–92. [3] Bereket W, Hemalatha K, Getenet B, et al. Update on bacterial nosocomial infections. European Review for Medical and Pharmacological Sciences 2012;16:1039–44.
439
[4] Gisbert JP. Is culture necessary before first-line treatment for Helicobacter pylori infection? Internal Medicine 2011;50:2717.
Davide Roccarina ∗ Francesco Franceschi Antonio Gasbarrini Internal Medicine Unit, Policlinico Gemelli, Rome, Italy ∗ Corresponding
author at: Internal Medicine Unit, Policlinico Gemelli, l.go A. Gemelli 8, Italy. Tel.: +39 3492620730. E-mail address: [email protected] (D. Roccarina) 14 January 2013 19 January 2013 Available online 29 January 2013
http://dx.doi.org/10.1016/j.dld.2013.01.027
Contents lists available at SciVerse ScienceDirect
Digestive and Liver Disease journal homepage: www.elsevier.com/locate/dld
Correspondence Comment to: “Different Antibiotic No Culture Eradication (DANCE) of Helicobacter pylori: An easy way to manage H. pylori eradication” Dear Editor, Successful Helicobacter pylori eradication prevents the potentially problematic outcome of Helicobacter colonisation. Unfortunately the success rate of H. pylori therapy has been falling due to a worldwide increase in antibiotic resistance [1]. The paper by Roccarina et al. [2] proposes a novel approach on the treatment of H. pylori infections which they refer to as the ‘DANCE strategy’. Their strategy essentially obviates the need for endoscopy and microbiological culture as it proposes to prescribe antibiotics empirically in a stepwise manner. Although this may be effective for individual patients we feel that such a strategy is bound to induce antibiotic resistance, and thus will eventually be harmful to the community. Treatment of H. pylori needs multiple antibiotics, and eradication rates already decline if there is resistance against one of the antibiotics in such a combination therapy [1]. As such a patient is factually treated with monotherapy, the likelihood of selection of resistance against the other still active antibiotic(s) increases, and this potentially results in multi-drug resistant isolates [1,3]. We firmly believe that avoiding antibiotic susceptibility testing, as proposed in the DANCE strategy will facilitate emergence of antibiotic resistance. There are numerous examples of infections where exactly the same has happened, such as for instance tuberculosis and HIV [4]. As there are only a handful of oral antibiotics effective against Helicobacter and since combination of two or three antibiotics and an acid inhibitor is required, we should prevent losing these treatment options. This avoidable selection of (multi-drug) resistant isolates may not only harm the individual patient, but may also harm newly infected patients, as in other infections. Indeed endoscopy and subsequent culture and susceptibility testing are not always possible. Yet, there are reliable methods to accurately determine presence of H. pylori in faeces, saliva and blood, such as ELISA and direct PCR [5]. As the molecular mechanisms of resistance of H. pylori are known [5] determination of these genes with molecular tests based on H. pylori DNA in faeces seems feasible [6]. The costs of molecular tests have dropped significantly and are nowadays similar to costs of ELISA or cultures. Therefore, considering the global emergence of antibiotic resistance among H. pylori we feel that the DANCE strategy is potentially harmful and that our efforts should be directed towards antibiotic susceptibility guided treatment of H. pylori infection, where possible.
Conflict of interest statement None.
References [1] De Francesco V, Giorgio F, Hassan C, et al. Worldwide H. pylori antibiotic resistance: a systematic review. Journal of Gastrointestinal and Liver Disease 2010;19:409–14. [2] Roccarina D, Franceschi F, Zocco MA, et al. Different Antibiotic No Culture Eradicating (DANCE) strategy: an easy way to manage H. pylori eradication. Digestive and Liver Disease 2012;44:889–92. [3] Selgrad M, Bornschein J, Malfertheiner P. Guidelines for treatment of Helicobacter pylori in east and west. Expert Review of Anti-Infective Therapy 2011, http://dx.doi.org/10.1586/eri.11.80. [4] Pasipanodya JG, Gumbo T. A new evolutionary and pharmacokinetic– pharmacodynamic scenario for rapid emergence of resistance to single and multiple anti-tuberculosis drugs. Current Opinion in Pharmacology 2011;11:457–63. [5] Mégraud F, Lehours P. Helicobacter pylori detection and antimicrobial susceptibility testing. Clinical Microbiology Reviews 2007;20:280–322. [6] Makristathis A, Hirschl AM, Lehours P, et al. Diagnosis of Helicobacter pylori infection. Helicobacter 2004;9(Suppl. 1):7–14.
Amin Talebi Bezmin Abadi Marc J. Bonten Johannes Gerardus Kusters ∗ Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands ∗ Corresponding
author at: Department of Medical Microbiology, University Medical Center Utrecht, Heidelberglaan, 100, 3584 CX Utrecht, The Netherlands. Tel.: +31 88 7553687/7556524. E-mail addresses: [email protected], [email protected] (J.G. Kusters) 12 November 2012 Available online 29 January 2013
http://dx.doi.org/10.1016/j.dld.2012.12.015
Author reply: Comment to “Different Antibiotic No Culture Eradicating (DANCE) strategy: An easy way to manage H. pylori eradication” Dear Editor, We have read the letter by Amin Talebi Bezmin Abadi et al. [1] criticizing the use of the “Different Antibiotic No Culture Eradicating (DANCE)” strategy to eradicate Helicobacter pylori (H. pylori) [2]. We are perfectly aware that antibiotic resistance is an emerging issue nowadays, and that treating patients with multiple antibiotics “empirically” may contribute to inducing such resistances [3]. However, we believe that the authors may have misunderstood the original message provided by our paper. In fact, we are in favour of applying new techniques to detect antibiotic resistance before deciding the best eradication regimen. Nevertheless, although simple and not excessively expensive, this strategy may not universally
1590-8658/$36.00 © 2013 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
Correspondence / Digestive and Liver Disease 45 (2013) 438–439
applicable, especially for patients referred primarily to low-volume peripheral centres [4]. Only in those selected cases do we propose the DANCE strategy, which in contrast should be avoided in highly specialized centres. Conflict of interest statement We certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. References [1] Abadi ATB, Bonten MJ, Kusters JG. Comment to “Different Antibiotic No Culture Eradication (DANCE) of Helicobacter”. Digestive and Liver Disease; in press. [2] Roccarina D, Franceschi F, Zocco MA, et al. Different Antibiotic No Culture Eradicating (DANCE) strategy: an easy way to manage H. pylori eradication. Digestive and Liver Disease 2012;44:889–92. [3] Bereket W, Hemalatha K, Getenet B, et al. Update on bacterial nosocomial infections. European Review for Medical and Pharmacological Sciences 2012;16:1039–44.
439
[4] Gisbert JP. Is culture necessary before first-line treatment for Helicobacter pylori infection? Internal Medicine 2011;50:2717.
Davide Roccarina ∗ Francesco Franceschi Antonio Gasbarrini Internal Medicine Unit, Policlinico Gemelli, Rome, Italy ∗ Corresponding
author at: Internal Medicine Unit, Policlinico Gemelli, l.go A. Gemelli 8, Italy. Tel.: +39 3492620730. E-mail address: [email protected] (D. Roccarina) 14 January 2013 19 January 2013 Available online 29 January 2013
http://dx.doi.org/10.1016/j.dld.2013.01.027