Articles
Long-term changes of gut microbiota, antibiotic resistance, and metabolic parameters after Helicobacter pylori eradication: a multicentre, open-label, randomised trial

https://doi.org/10.1016/S1473-3099(19)30272-5Get rights and content

Summary

Background

In first-line treatment of Helicobacter pylori, we have previously shown that the eradication frequency was 83·7% (95% CI 80·4–86·6) for triple therapy for 14 days (T14; lansoprazole 30 mg, amoxicillin 1 g, and clarithromycin 500 mg, all given twice daily), 85·9% (82·7–88·6) for concomitant therapy for 10 days (C10; lansoprazole 30 mg, amoxicillin 1 g, clarithromycin 500 mg, and metronidazole 500 mg, all given twice daily), and 90·4% (87·6–92·6) for bismuth quadruple therapy for 10 days (BQ10; bismuth tripotassium dicitrate 300 mg four times a day, lansoprazole 30 mg twice daily, tetracycline 500 mg four times a day, and metronidazole 500 mg three times a day). In this follow-up study, we assess short-term and long-term effects of these therapies on the gut microbiota, antibiotic resistance, and metabolic parameters.

Methods

This was a multicentre, open-label, randomised trial done at nine medical centres in Taiwan. Adult patients (>20 years) with documented H pylori infection were randomly assigned (1:1:1, with block sizes of six) to receive T14, C10, or BQ10. We assessed long-term outcomes (reinfection frequency, changes in the gut microbiota, antibiotic resistance, and metabolic parameters) in patients with available data, excluding all protocol violators and those with unknown post-treatment H pylori status. Faecal samples were collected before treatment and 2 weeks, 2 months, and at least 1 year after eradication therapy. Amplification of the V3 and V4 hypervariable regions of the 16S rRNA was done followed by high-throughput sequencing. Susceptibility testing for faecal Escherichia coli and Klebsiella pneumoniae was done. This trial is complete and registered with ClinicalTrials.gov, NCT01906879.

Findings

Between July 17, 2013, and April 20, 2016, 1620 participants were randomly assigned to the three treatment groups (540 [33%] per group). 1214 (75%) attended 1-year follow-up and are included in this analysis. Compared with baseline, alpha diversity was significantly reduced 2 weeks after T14 (p=0·0002), C10 (p<0·0001), and BQ10 (p<0·0001) treatment. Beta diversity was also significantly altered 2 weeks after T14 (p=0·0010), C10 (p=0·0001), and BQ10 (p=0·0001). Alpha diversity and beta diversity were restored at week 8 (p=0·14 and p=0·918, respectively) and 1 year (p=0·14 and p=0·918) after T14, but were not fully recovered at week 8 and after 1 year in patients treated with C10 (p=0·0001 and p=0·013 at week 8; p=0·019 and p=0·064 at 1 year) and BQ10 (p<0·0001 and p=0·0002; p=0·001 and p=0·029). A transient increase at week 2 after T14 and C10 of the resistance rates of E coli to ampicillin-sulbactam (12% [15/127] to 66% [38/58] for T14, 7% [10/135] to 64% [28/44] for C10), cefazolin (13% [16/127] to 43% [25/58] for T14, 10% [13/135] to 41% [18/44] for C10), cefmetazole (8% [10/127] to 26% [15/58] for T14, 4% [5/135] to 18% [8/44] for C10), levofloxacin (8% [10/127] to 35% [20/58] for T14, 7% [10/135] to 32% [14/44] for C10), gentamicin (13% [19/146] to 47% [27/58] for T14, 15% [22/149] to 45% [20/44] for C10), and trimethoprim–sulfamethoxazole (33% [48/146] to 86% [50/58] for T14, 28% [42/148] to 86% [38/44] for C10; p<0·05 in paired samples in the above analyses) returned to basal state at week 8 and after 1 year. Although bodyweight and body-mass index slightly increased, there were significant improvements in metabolic parameters, with a decrease in insulin resistance, triglycerides, and LDL and an increase in HDL. Overall, there was no significant change in the prevalence of metabolic syndrome at week 8 and 1 year after T14, C10, and BQ10.

Interpretation

Eradication of H pylori infection has minimal disruption of the microbiota, no effect on antibiotic resistance of E coli, and some positive effects on metabolic parameters. Collectively, these results lend support to the long-term safety of H pylori eradication therapy.

Funding

National Taiwan University Hospital and Ministry of Science and Technology of Taiwan.

Introduction

Eradication of Helicobacter pylori infection reduces the recurrence of peptic ulcer disease and the incidence of gastric cancer.1, 2, 3, 4 Triple therapy comprising a proton pump inhibitor (PPI), amoxicillin and clarithromycin, concomitant therapy (PPI plus amoxicillin, clarithromycin, and metronidazole), and bismuth quadruple therapy (PPI plus bismuth, tetracycline, and metro-nidazole) are the most commonly used regimens for H pylori eradication.1, 5, 6, 7 However, there are several concerns and barriers regarding the widespread use of antibiotics as a preventive measure against gastric cancer, including the emergence of antibiotic resistance,8, 9, 10, 11, 12 the perturbation of gut microbiota,13, 14, 15, 16 and the development of metabolic syndrome after H pylori eradication.17, 18, 19, 20 Yet, few studies have addressed the long-term effect of H pylori eradication on these important issues. Emerging evidence shows that dysbiosis of the gut microbiota is associated with metabolic syndrome, diabetes, and cardiovascular diseases.21, 22, 23 The association of H pylori and these same extragastric diseases might also be attributed to the gut microbiota.17, 18, 19, 20 Antibiotics are important modulators of the gut microbiome,24 but different antibiotics might exert differential effects on the gut microbiota and antibiotic resistance.24, 25 Some small-scale studies showed that short courses of triple therapy might lead to long-term dysbiosis of gut microbiota.13, 14, 15, 16 However, the short-term and long-term effects of different eradication regimens on the gut microbiota, antibiotic resistance, and metabolic para-meters have not been reported. In a multicentre, randomised trial in Taiwan,7 we showed that 10-day bismuth quadruple therapy (90·4% [488/540], 95% CI 87·6–92·6), but not 10-day concomitant therapy (85·9% [464/540], 82·7–88·6), was superior to 14-day triple therapy (83·7% [452/540], 80·4–86·6) in the first-line treatment of H pylori infection. The prespecified secondary endpoints of this trial, including the long-term effect of the three regimens on the gut microbiota, metabolic parameters, and antibiotic resistance of gut microbiota, are presented in this Article.

Research in context

Systematic review

We searched PubMed using the terms “H. pylori”, “eradication”, “long-term”, and “microbiota”, for papers published from Jan 1, 2000, to Nov 10, 2018, without language restrictions. We found no randomised trials that compared the long-term (≥1 year) changes of gut microbiota after triple therapy, concomitant therapy, and bismuth quadruple therapy for Helicobacter pylori eradication. We identified three studies that reported the long-term changes in the gut microbiota after H pylori eradication. Jakobsson and colleagues showed that the diversity of the microbiota recovered to resemble the pretreatment states, with some notable changes at the genus levels at 1 year and 4 year after triple therapy, but formal statistical analysis was not done owing to small sample size (six patients). Yap and colleagues also showed no significant differences in richness and evenness of bacterial species, but they found some notable changes at the phylum and genus levels after triple therapy (17 patients). Hsu and colleagues reported that the relative abundances of all phyla restored to the amounts at baseline at 48 weeks after bismuth quadruple therapy (11 patients). We identified another four studies that only reported the short-term changes in the gut microbiota after H pylori eradication (20–70 patients each). These studies showed significant changes in diversity shortly after H pylori eradication.

We did a further PubMed search using the terms “H. pylori”, “eradication”, “long-term”, and “resistance”, for papers published up to Nov 10, 2018, without language restrictions. We identified one brief communication that compared clarithromycin resistance of enterococci in five patients before and 1 year after triple therapy with five controls who did not receive antibiotics. In that study, numerically higher clarithromycin resistance prevalence was observed in patients who received triple therapy (two [50%] of four), compared with none of the controls. We searched the Web of Science to identify articles that cited this study and identified another study that compared clarithromycin resistance rates of Staphylococcus spp, Streptococcus spp, Enterococcus spp, and Bacteroides spp in 85 patients who received triple therapy and 12 controls who did not. They reported numerically higher resistance rates of staphylococcus against clarithromycin in patients who received triple therapy at 1 year (20 [34%] of 58), compared with the control group (two [20%] of ten). However, the difference was not significant.

Finally, we searched PubMed using the terms “H. pylori”, “eradication”, and “insulin resistance” for papers published up to Nov 10, 2018, without language restrictions. We identified six prospective and retrospective studies that reported the short-term changes (6–12 weeks) of insulin resistance after H pylori eradication. These studies showed contradictory results. None of them assessed the long-term changes of insulin resistance after H pylori eradication.

Added value of this trial

To our knowledge, this is the first large-scale randomised trial to show the distinct short-term and long-term effects of triple therapy, concomitant therapy, and bismuth quadruple therapy on the gut microbiota, antibiotic resistance, and metabolic parameters. We found that short-term perturbation of gut microbiota and short-term increase of antibiotic resistance of E coli were restored at 1 year after H pylori eradication. However, the speed and extent of restoration of gut microbiota varied with regimens. Whereas the gut microbiota was less perturbed by triple therapy, bismuth quadruple therapy induced minimal increase in the antibiotic resistance of E coli. Although there were trivial increases in body-mass index and bodyweight, insulin resistance and triglyceride concentrations decreased, indicating potential beneficial metabolic effects after H pylori eradication.

Interpretation of all the available evidence

Eradication of H pylori infection has minimal disruption of the microbiota, no effect on antibiotic resistance of E coli, and some positive effects on metabolic parameters. These findings collectively lend support to the long-term safety of H pylori eradication therapy. Taken together with our previous study, bismuth quadruple therapy is recommended in regions with clarithromycin resistance of greater than 15% because it is more effective than triple therapy, its efficacy is less affected by clarithromycin resistance, and it exerts minimal effects on the antibiotic resistance of E coli and Klebsiella pneumoniae. Triple therapy for 14 days exerts minimal perturbation of gut microbiota and might be an alternative therapy in regions with clarithromycin resistance of less than 10–15%.

Section snippets

Study design and patients

Detailed methods for this multicentre, open-label, rando-mised trial were published in our previous report for the primary outcome and short-term secondary outcomes.7 In brief, adult patients (>20 years) with at least two positive tests among histology, culture, rapid urease test, and serology were eligible (criterion 1). Asymptomatic patients with a single positive 13C-urea breath test (13C-UBT) were also eligible (criterion 2). Patients with any one of the following criteria were excluded

Results

Between July 17, 2013, and April 20, 2016, we screened 5454 patients, of whom 1620 (30%) were randomly assigned to treatment (540 [33%] per group). 1214 patients had data on long-term outcomes (table 1, appendix p 4). Of 1195 successfully treated patients, reinfection or recrudescence was observed in 12 (3%) of 404 patients treated with triple therapy, ten (3%) of 399 treated with concomitant therapy, and 13 (3%) of 392 treated with quadruple therapy after 1·6 years (p=0·80; table 1).

At

Discussion

To our knowledge, this is the first large-scale, randomised trial to show the distinct short-term and long-term effects of triple therapy, concomitant therapy, and bismuth quadruple therapy on the gut microbiota, antibiotic resistance, and metabolic health parameters (table 3). As expected with any antibiotic treatment, we observed significant perturbations of the gut microbiota at the end (week 2) of H pylori eradication therapy with the three regimens, but to a significantly greater extent

Data sharing

The study protocol and statistical analysis plan are published online. Appropriate academic parties may contact Jyh-Ming Liou ([email protected]) for the de-identified participant dataset that underlies the results reported in this article, in accordance with the data sharing policies of National Taiwan University and Ministry of Health and Wealth, Taiwan, with input from the investigator group where applicable after receipt of the research proposal.

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