Efficacy of Omeprazole, Tetracycline, and 4 Times Daily Dosing of Amoxicillin in Helicobacter pylori Eradication in Limited Resource Area in Bhutan: A Prospective Randomized Trial (BHUTAN Study).

Backgrourd: H. pylori-associated gastric cancer is the first cancer-related death in Bhutan. Effective regimen for H. pylori eradication is essential to reduce risk of developing gastric cancer. Clarithromycin is not widely used in this limited resource country. Aim of this study was to evaluate proper regimen and prevalence of antibiotic resistance pattern for H. pylori eradication in Bhutan. METHODS: Five hundred and forty-six patients underwent gastroscopy during GASTROCAMP between October 2014 and April 2015 in Bhutan and 77 patients were enrolled. Four gastric biopsies were obtained for rapid urease test, histopathology, H. pylori culture with Epsilometer test. All H. pylori-positive patients were randomized to receive either 7-day or 14-day of 500 mg amoxicillin four times daily, 500 mg tetracycline four times daily, and 20 mg omeprazole twice daily. RESULTS: Seventy-seven subjects were enrolled (54 females, 23 males, mean age = 45.4 years). Of 77 patients, 52 (67.5%) received 7-day regimen while 25 (32.5%) had 14-day regimen. Prevalence of H. pylori was 38.2%. Antibiotic resistance was 80.0% for metronidazole, 11.1% for levofloxacin and no resistance seen in amoxicillin, tetracycline and clarithromycin. Overall eradication rates of 7-day and 14-day regimens were 51.9% and 80.0%, p = 0.02. Female and age ≥40 years had significantly higher eradication rate when receiving 14-day compared to 7-day regimen (94.1% vs. 45.9%, OR = 18.82; 95% CI 2.26-157.02, p = 0.0007 and 86.7% vs. 50.0%, OR = 6.50; 95% CI 1.25-33.91, p = 0.02, respectively). CONCLUSIONS: Fourteen-day regimen might be an acceptable regimen for H. pylori eradication in limited resource area such as Bhutan. Female and age ≥40 years should receive longer duration of treatment. This 14-day regimen could at least reduce the risk of developing H. pylori-associated diseases especially peptic ulcer with complications and gastric cancer which lead to many deaths in Bhutan.
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High Fluoroquinolone Resistant Strains of Helicobacter pylori in the Golden triangle

Background and aims: Helicobacter pylori (H. pylori) infections, associated with fatal GI diseases such as gastric cancer and MALT lymphoma, remain a major health problem in ASEAN countries. The Golden triangle has long been known as one of Asia's main opium-producing areas. There have been no prior studies of H. pylori infection in this area. The major objectives of this project were therefore to establish prevalence, antibiotic resistance patterns and associated predictive in the Golden triangle. Methods: We recruited dyspeptic patients in Chiang khong and Chiang saen districts, Chiangrai province of Thailand. All subjects underwent gastroscopy, and 3 antral gastric biopsies were collected for rapid urease tests and H. pylori culture. E-tests were used to evaluate the MICs for metronidazole (MNZ), levofloxacin (LVX), ciprofloxacin (CIP), amoxicillin(AMX), tetracycline (TET) and clarithromycin (CLR). Results: Total of 148 patients was included. H. pylori infection was present in 36.3%(37/102) of Chiang khong and 34.8 % (16/46) of Chiang saen subjects and the overall H. pylori infection rate was 35.8% (53/148). Antibiotic resistance was demonstrated in 44%, including 2% for CLR and 26% for MNZ, whereas fluoroquinolone resistance was demonstrated to be as high as 25% in Chiang khong. Multi-drug resistant H. pylori was detected in 4%. There was no AMX and TET resistance in this study. The prevalence of CLR resistance on a background of gastritis was significantly higher than peptic ulcer disease in the golden triangle area (100%vs 0%: P= 0.04). Conclusions: H. pylori remains a common infection in the Golden triangle. MNZ resistance appears to be high, whereas fluoroquinolone resistance is prevalent and is becoming a significant problem in this area. Diagnosis of gastritis might be a predictor of CLR resistance in the Golden triangle. H. pylori eradication with an appropriate regimen by using the local antibiotic resistant pattern is a key important tool to reduce H. pylori associated GI diseases in this particular part of the world.