Stool tests provide speedy results for predicting H. pylori antibiotic resistance
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LAS VEGAS – Using next generation sequencing through stool samples to predict Helicobacter pylori antibiotic resistance offered rapid results equivalent to those from gastric biopsies, according to a presentation at the ACG Scientific Meeting.
“The bottom line is that the availability of the stool-based test will make it much easier to choose an H. pylori eradication regimen in difficult cases, such as after failure of a first line therapy,” Steven Moss, MD, a clinical gastroenterologist at Rhode Island Hospital and director of the Brown University Gastroenterology Fellowship Training Program, both in Providence, Rhode Island, told Healio Gastroenterology. “The choice can now be based on scientific principles rather than guesswork.”
Moss and colleagues enrolled 262 patients who were scheduled for upper endoscopy from four clinical practices. Investigators collected two gastric biopsies for next generation sequencing (NGS). Within 2 weeks of endoscopy and prior to H. pylori therapy, a spontaneously passed stool was collected. Polymerase chain reaction was used to conform H. pylori in biopsies. In order to identify mutations correlated with H. pylori antibiotic resistance, investigators performed NGS.
In stool samples, H. pylori was confirmed with fecal antigen tests and PCR. Positive samples were examined by NGS to predict the resistance to amoxicillin, clarithromycin, metronidazole, tetracycline, levofloxacin and rifabutin.
Of the 262 patients, 73 (29%; mean age, 61 years; age range, 18-83 years; 41 women) were positive for H. pylori by stool testing, of which two did not have sufficient gastric DNA for analysis. Researchers collected stool and biopsy samples for the six antibiotics from the remaining 71 patients. There were identical profiles for stool and biopsy results in 91.5% of patients. Moss noted six patients had mismatched gastric and stool results. This was due to one antibiotic-associated mutation difference in four of the patients. At least one resistance-associated mutation was noted in 70.4% of gastric biopsies. There were 21 patients with no mutations.
“Resistance is a major cause of treatment failure for H. pylori eradication,” Moss said during the presentation. “These results confirm that with high resistance to clarithromycin, metronidazole and levofloxacin, we really should not be using triple therapies without susceptibility data.”
Moss told Healio Gastroenterology that future directions include assessing how using the stool test will improve clinical outcomes in practice.
Perspective
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Adrienna Jirik, MD
Antimicrobial resistance is an ever-growing problem for successful eradication of H. pylori, which is the most common chronic bacterial infection in humans and associated with 89% of gastric cancers. The relative paucity of high-quality evidence to guide personalized therapy in patients, which includes important information on antimicrobial resistance, exacerbates this issue. The American Gastroenterology Association has recently released updated practice guidelines on refractory H. pylori infections and highlights the fact that even though susceptibility testing has been recommended for many years, empiric treatment persists worldwide. This has contributed to very high global resistance patterns to clarithromycin, levofloxacin and metronidazole — long-standing mainstay drugs used in the most prescribed empiric H. pylori treatment regimens.
Moss’s study using next generation sequencing through stool samples is a promising, noninvasive step toward identifying mutations associated with resistance and offers more targeted therapy for patients, especially in those with previous treatment failure. Further investigation is naturally needed to ensure translational efficacy in clinical medicine, but if this proves to provide reliable high accuracy data, it could provide an avenue for regular, high resistance screening for all patients who are candidates for treatment prior to starting any antibiotic regimen to ensure optimal rates of first-time eradication and minimize repeated antibiotic exposure.
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Moss S, et al. Abstract: S1381. ACG Annual Scientific Meeting; Oct. 22-27, 2021; Las Vegas (hybrid meeting).
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