• Journal of Microbiology and Biotechnology
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• v.13 no.5
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• pp.751-758
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• 2003

Mutations in the rdxA gene had been reported to be associated with metronidazole resistance in Helicobacter pylori. In this study, sensitivity to metronidazole, RAPD profiles, and DNA sequences of the rdxA gene of 32 local H. pylori isolates were analyzed. Of these, 13 were found to be resistant, while 19 were sensitive to metronidazole. Among the 32 isolates, 10 were paired isolates from the antrum and body of the stomach of individual patients. Interestingly, the RAPD profiles of isolates from individual patients were distinctly different from each other, whereas paired isolates from the same patient were identical regardless of their sensitivities to metronidazole. DNA sequences of the rdxA gene of all 32 isolates showed 95% to 97% homology when compared with the HP0954 locus of H. pylori 26695 genome. From the 19 metronidazole-sensitive strains, 10 (with $MIC{\le}0.5\;\mu\textrm{g}/ml$ metronidazole) were selected and induced to become metronidazole resistant by sequentially passaging through serial 2-fold increasing concentrations of metronidazole. Nine of the 10 induced paired isolates showed mutations in the rdxA sequences which resulted in truncated protein or changes in the translated amino acid sequences. However, the changes did not occur at any specific site in the DNA or amino acid sequences of the rdxA gene of all the isolates analyzed. The results show that the rdxA gene cannot be a definitive marker for metronidazole resistance in H. pylori isolates of an Asian population, and that other factors may contribute to resistance to metronidazole.

• Journal of Life Science
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• v.15 no.6 s.73
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• pp.955-960
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• 2005

Resistance to metronidazole, a key component of therapies against Helicobacter pylori, is common in clinical isolates. Resistance generally requires inactivation of rdxA (HP0954), and sometimes also frxA (HP0642), two related nitroreductase genes. Here we studied the effect of resistance to metronidazole on fitness of the gastric pathogen H. pylori. The effect of metronidazole resistance for H. pylori in culture was assessed first by looking at colonies formed by freshly constructed mutant derivatives of H. pylori strain 26695. Mutations resulting in metronidazole resistance caused premature death of H.pylori in stationary phase, but had no significant effect on early exponential growth. The effect of nitroreductase deficiencies on fitness in vivo was tested by infecting C57BL/6 mice with 1:1 mixtures of SS1 wild type and its isogenic metronidazole resistant derivatives. Inactivation of rdxA caused an inability to colonize mice in SS1 H. pylori strain. Derivatives of a metronidazole resistant strain that survived better in stationary phase, although remaining metronidazole resistant, could again colonize mice. In conclusion, metronidazole resistance diminishes H. pylori's fitness, but their costs can be suppressed by additional mutation.

• YAKHAK HOEJI
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• v.52 no.3
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• pp.225-231
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• 2008

To clarify effects of the structural changes of Fur protein on the resistance to metronidazole (Mtz), the mutational analysis of structure and function of the protein in Helicobacter pylori (Hp) was undertaken. It was identified that some changes in Hp Fur protein resulted in increase of resistance to Mtz, and other changes resulted in decrease of resistance. Increase of Mtz resistance came from the enzyme's decreased ability of reducing prodrug Mtz to the form of bactericidal agent. Some sites that affects Mtz resistance (i) in Fur's N terminal extension, and (ii) in its central region, which links DNA binding and Fe-binding modules were identified. It was also found that the addition of FLAG tag to Fur's C terminus also significantly impairs Fur function.

• Journal of Life Science
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• v.17 no.5 s.85
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• pp.723-727
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• 2007

Resistance to metronidazole in Helicobacter pylori results from inactivation of rdxA and frxA, the chromosomal genes for a nitroreductase that normally converts metronidazole from prodrug to bactericidal agent. Two types of metronidazole susceptible strains had been found distinguishable by their apparent levels of frxA expression. Most common in the populations we had studied were strains that required only rdxA inactivation to become resistant to moderate levels of metronidazole(type I strains). The second strain type required inactivation of both frxA and rdxA to become resistance to metronidazole(type II strains): this was linked to a relatively high level of frxA gene transcription in the type II strains. The fdxA gene regulated fdxA as well as rdxA gene. Thus, to study the function of fdxA as a regulatory gene we constructed a null mutant of fdxA in H. pylori genome and identified over-and under-expressed proteins by fdxA using two-dimensional(2-D) electrophoresis and MALDI-TOP-MS. There were four over-expressed proteins in fdxA mutant; nifU-like protein(HP0221), frxA(HP0642), nonheme ferritin(HP0653), and hypothetical protein(HP0902). Three under-expressed proteins were also identified in fdxA mutant, including 5'-methylthioadenosine/S-adenosylhomocysteine nucleosidase (HP0089), (3R)-hydroxymyristoyl ACP dehydratase(HP1376), and thioredoxin(HP1458).

• Asian Pacific Journal of Cancer Prevention
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• v.16 no.14
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• pp.6089-6092
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• 2015

Background: The prevalence of metronidazole-resistant H. pylori is almost 50% in Thailand which severely limits the use of this drug for eradication therapy. The aims of this study were to evaluate the efficacy and safety profiles of 7-day bismuth-based quadruple therapy including metronidazole as an initial treatment for H. pylori infection in a high metronidazole resistance area. Materials and Methods: This study was performed at Thammasat University Hospital and King Chulalongkorn Memorial Hospital during January 2009 to October 2010. Patients with non-ulcer dyspepsia (NUD) with active H. pylori infection were assigned to receive seven days of quadruple therapy (pantoprazole 40 mg bid, bismuth subsalicylate 1,048 mg bid, amoxicillin 1 gm bid and metronidazole 400 mg tid). H. pylori infection was defined as positive H. pylori culture or two positive tests (rapid urease test and histology). Antibiotic susceptibility test for metronidazole by Epsilometer test (E-test) was performed in all positive cultures. At least four weeks after treatment, $^{13}C$ urea breath test ($^{13}C-UBT$) was performed to confirm H. pylori eradication. Results: A total of 114 patients were enrolled in this study, 50 males and 64 females with a mean age of 49.8 years. All 114 patients had a diagnosis of NUD. Overall eradication as confirmed by negative $^{13}C-UBT$ was achieved in 94 out of 114 patients (82.5%). 44 patients had positive cultures and success for E-test. In vitro metronidazole resistance was observed in 22/44 (50%) patients. Eradication rate in patients with metronidazole resistant strains was 16/22 (72.7%) and 20/22 (90.1%) with metronidazole sensitive strains (72.7% vs 90.1%, p-value=0.12; OR=3.75 [95%CI=0.6-31.5]). Minor adverse reactions included nausea, bitter taste, diarrhea and black stools but none of the patients dropped out from the study. Conclusions: Initial treatment with 7-day bismuth-based quadruple therapy including metronidazole, amoxycillin and pantoprazole is highly effective and well tolerated for metronidazole-sensitive H. pylori infections. However, the efficacy markedly decline with metronidazole resistance. Longer duration of this regimen might be required to improve the eradication rate and larger multi-center studies are needed to confirm this hypothesis.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.14 no.1
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• pp.45-51
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• 2011

Purpose: The antimicrobial resistance of Helicobacter pylori is one of the critical factors in failure of eradication therapy. The purpose of this study was to evaluate antimicrobial resistance of H. pylori in Korean children. Methods: Gastric mucosal specimens for H. pylori were obtained from children with dyspepsia who were cared for at Asan Medical Center Children's Hospital in Seoul, Korea between 2003 and 2009. Antimicrobial resistance tests were performed using the disk diffusion method for clarithromycin and amoxicillin and the E-test for metronidazole and tetracycline. Most children with H. pylori infections were treated using triple therapies. Results: Thirty-three children had positive H. pylori cultures, although a resistance test was only performed in 28 patients. Resistant strains were found in 9 children (32.1%). The resistance rates to clarithromycin and metronidazole were 25% and 17.8%, respectively. There was no resistance to amoxicillin or tetracycline. The resistance rates decreased from 44.4% (2003~2006) to 26.3% (2006~2009) during the study period. Conclusion: Korean children demonstrated relatively high antimicrobial resistance to H. pylori in this study. However, there was a temporarily decreasing trend during the study period. A larger multi-regional study may be needed to determine the optimal antimicrobial treatment for pediatric patients infected with H. pylori.

• Journal of Microbiology and Biotechnology
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• v.9 no.3
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• pp.328-333
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• 1999

Susceptibility of 61 strains of Helicobacter pylori to metronidazole was examined by both the disk diffusion method using a cut-off of 15㎜ for resistance and the E test with a cut-off of 8㎎/l. The MIC/sub 50/ and MIC/sub 90/ by the E test were 2 ㎎/l and 256㎎/l, respectively. Metronidazole resistance was found in 22 (36％) out of the 61 H. pylori strains by the E test and in three additional strains by the disk diffusion method. Amongst the latter three isolates, the MICs by the E test were 4 ㎎/l, 6㎎/l, and 6㎎/l, respectively. These figures are one log₂ or half log₂ dilution lower than the cut-off of 8㎎/l recommended as resistance for the E test. All 22 metronidazole resistant H. pylori isolates by the E test that were subjected to random amplified polymorphic DNA (RAPD) fingerprinting showed different DNA fingerprints. Interestingly, >90％ of resistant isolates possess two common DNA bands of 0.4 and 0.9 kb. This study demonstrates that the results of the disk diffusion method for testing H. pylori susceptibility to metronidazole correlates well with that of the E test. The criteria for interpretation need to be internationally standardized so that the results from different centers can be compared.

• The Journal of the Korean Society for Microbiology
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• v.34 no.6
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• pp.543-554
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• 1999

The purpose of this study was to evaluate the existence of amoxicillin, clarithromycin, and metronidazole resistance Helicobacter pylori and to determine the in-vitro MIC of two and three kinds of antibiotic concominant administration in the isolates. The antimicrobial agents tested against 169 H. pylori included metronidazole, amoxicillin, ciprofloxacin, clarithromycin, omeprazole, josamycin, erythromycin, and tetracycline. MIC of each antimicrobial agents was determined by broth microdilution method. The 169 strains of H. pylori were isolated from biopsy specimens of patients with gastric cancer. $MIC_{50}$ of clarithromycin, amoxicillin, metronidazole, omeprazole, erythromycin, josamycin, tetracycline, and ciprofloxacin was 2.0, 1.0, 4.0, 8.0, 0.5, 0.5, and $0.5\;{\mu}g/ml$, respectively. $MIC_{90}$ of clarithromycin, amoxicillin, metronidazole, omeprazole, erythromycin, josamycin, tetracycline, and ciprofloxacin was 64.0, 64.0, 32.0, 16.0, 8.0, 2.0, and $1.0\;{\mu}g/ml$, respectively. H. pylori isolates were detected in the following resistaince rates: 34.3% to clarithromycin, 31.9% to metronidazole, 20.7% to amoxicillin, 12.4% to erythromycin, and 10.1% to josamycin. The prevalence of the antibiotic resistant strains of H. pylori were detected 18.1% for two kind of antibiotics and 9.6% for three kind of antibiotics, and 3.9% for four kind of antibiotics. The $MIC_{90}$ of clarithromycin-, metronidazole-, and amoxicillin-resistant H. pylori was decreased under the $1\;{\mu}g/ml$ by the two or three kind of antibiotic concomitant administration in-vitro. These results suggest that two or three antibiotics concomitant administration could be more effective for the treatment of clarithromycin-, amoxicillin-, metronidazole-, and josamycin-resistant H. pylori strains.

• The Korean journal of helicobacter and upper gastrointestinal research
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• v.18 no.4
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• pp.242-246
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• 2018

Background/Aims: Helicobacter pylori eradication rates using first-line treatment have decreased due to clarithromycin resistance. The aim of this study was to investigate optimal eradication regimens for patients with clarithromycin resistance in Korea. Materials and Methods: A total of 72 patients with confirmed clarithromycin resistance were enrolled from August 2015 to July 2017. Patients were randomized to a 7-day bismuth quadruple therapy (BQT) regimen or a 7-day metronidazole triple therapy (MTT) regimen. Eradication was confirmed using the $^{13}C$-urea breath test. Results: There were no differences in baseline characteristics between the groups. Intention-to-treat eradication rates were 77.8% for the BQT group and 66.7% for the MTT group (P=0.293). Per protocol eradication rates were 87.5% for the BQT group and 77.4% for the MTT group (P=0.292). Adverse events were more frequent in the BQT group. Conclusions: Eradication rates using MTT were comparable to those using BQT, and adverse events were less frequent in the MTT group. Thus, MTT may be considered as a first-line regimen for patients with clarithromycin resistance. Since this was a pilot study, a study with a large group is required.

• Asian Pacific Journal of Cancer Prevention
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• v.16 no.10
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• pp.4353-4356
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• 2015

Background: Levofloxacin is an effective medication for second line Helicobacter pylori (H. pylori) eradication. However, limited studies have approved its use as an effective antibiotic in first line therapy. Dexlansoprazole is a new PPI and lacks of evidence in support of a role in H. pylori eradication. This study was designed to evaluate efficacy of levofloxacin-dexlansoprazole-based quadruple therapy for H. pylori eradication in Thailand. Materials and Methods: This prospective randomized control study was performed during June 2014 to December 2014. H. pylori infected gastritis patients were randomized to receive 7- or 14-day levofloxacin-dexlansoprazole based on quadruple therapy (levofloxacin 500 mg OD, dexlansoprazole 60 mg bid, clarithromycin MR 1000 mg OD, bismuth subsalicylate 1048 mg bid). CYP2C19 genotyping and antibiotic susceptibility tests were conducted for all patients. A 13C urea breath test was performed to confirm H. pylori eradication at least 4 weeks after treatment. Results: A total of 100 patients were enrolled, comprising 44 males and 56 females (mean age of 52.6 years). Eradication rate by PP analysis was 85.7% (42/49) with the 7-day regimen and 98% (48/49) with the 14-day regimen (85.7% vs 98%; p-value=0.059). ITT analysis was 84% and 96% with 7- and 14-day regimens, respectively (84% vs 96%; p-value=0.092). Antibiotic susceptibility testing demonstrated 35.1% resistance to metronidazole, 18.3% to clarithromycin, and 13.5% to levofloxacin. CYP2C19 genotyping revealed 54.1% RM, 34.7% IM and 11.2% PM. The 14-day regimen provided 100% eradication in patients with clarithromycin or dual clarithromycin and metronidazole H. pylori resistant strains. Moreover, the eradication rate was 96.6% in patients with CYP2C19 genotype RM. Conclusions: The 14-day levofloxacin-dexlansoprazole based quadruple therapy provides high H. pylori eradication regardless of CYP2C19 genotype, clarithromycin or dual clarithromycin and metronidazole resistant strains. This regimen could be use as an alternative first line therapy for H. pylori eradication in Thailand.