ORIGINAL RESEARCH

published: 16 April 2019

doi: 10.3389/fphar.2019.00394

Initial Trials With

Susceptibility-Based and Empiric
Anti-H. pylori Therapies in Mongolia
Tsogt-Ochir Byambajav 1 , Namdag Bira 1 , Gotov Choijamts 2 , Duger Davaadorj 1 ,
Boldbaatar Gantuya 1,3 , Tserenchimed Sarantuya 4 , Gidaagaya Sarantuya 4 ,
Altangerel Enkhtsetseg 5 , Dungubat Erdenetsogt 1 , Adiyasuren Battulga 6 ,
Tegshee Tserentogtokh 7 , Takeshi Matsuhisa 8 , Yoshio Yamaoka 3,9* and
Khasag Oyuntsetseg 1*
1
Department of Gastroenterology and Hepatology, School of Medicine, Mongolian National University of Medical Sciences,
Ulaanbaatar, Mongolia, 2 Department of Pharmacology, Otoch Manramba University of Mongolia, Ulaanbaatar, Mongolia,
3
Department of Environmental and Preventive Medicine, Faculty of Medicine, Oita University, Yufu, Japan, 4 Department
of Internal Medicine, Intermed Hospital, Ulaanbaatar, Mongolia, 5 Department of Laboratory, General Hospital of Defense
and Law Enforcement, Ulaanbaatar, Mongolia, 6 Department of Endoscopy, Ulaanbaatar Songdo Hospital, Ulaanbaatar,
Mongolia, 7 Department of Gastroenterology, State Central Third Hospital, Ulaanbaatar, Mongolia, 8 Department
of Gastroenterology, Nippon Medical School, Tama-Nagayama University Hospital, Tama-Nagayama, Japan,
9
Gastroenterology and Hepatology Section, Department of Medicine, Baylor College of Medicine, Houston, TX,
United States
Edited by:
Raffaele Capasso,
University of Naples Federico II, Italy Background: Mongolia has a high prevalence of Helicobacter pylori infection and
Reviewed by: gastric cancer. We conducted a prospective, randomized, single-blind study to evaluate
Ratha-korn Vilaichone,
the efficacy of common regimens in Mongolia and to obtain specimens for susceptibility
Thammasat University, Thailand
Josette Raymond, testing.
Université Paris Descartes, France
Methods: Empiric treatments: 270 patients with confirmed H. pylori infection were
*Correspondence:
Yoshio Yamaoka randomized to receive 10 days clarithromycin-triple therapy (Clari-TT) (n = 90), modified
[email protected] bismuth quadruple therapy (M-BQT) (n = 90), or sequential therapy (ST) (n = 90).
Khasag Oyuntsetseg
[email protected]
A second group of 46 patients received susceptibility-based Clari-TT. H. pylori was
cultured from 131 patients and susceptibility testing was performed. H. pylori eradication
Specialty section: was confirmed by stool antigen 4 weeks after the therapy.
This article was submitted to
Gastrointestinal and Hepatic Results: Intention-to-treat (ITT) analysis cure rates were 71.1% (95% CI = 61.7–80.5%)
Pharmacology,
a section of the journal
for Clari-TT, 87.8% (95% CI = 81–94.6%) for M-BQT, 67.8% (95% CI = 58.1–77.5%)
Frontiers in Pharmacology for ST vs. 89.1% (95% CI = 86–98.2%) for susceptibility-based Clari-TT. Per-protocol
Received: 17 January 2019 (PP) analysis results for these therapies were 72.7% (63.4–82%), 89.8% (83.5–96.1%),
Accepted: 29 March 2019 68.5% (58.8–78.2%), and 97.6% (89.5–99.8%), respectively. Among 131 cultured
Published: 16 April 2019
H. pylori, resistance rates to amoxicillin, clarithromycin, and metronidazole were 8.4,
Citation:
Byambajav T-O, Bira N, 37.4, and 74%, respectively.
Choijamts G, Davaadorj D,
Gantuya B, Sarantuya T, Sarantuya G,
Conclusion: In Mongolia, the prevalence of H. pylori resistance is high requiring bismuth
Enkhtsetseg A, Erdenetsogt D, quadruple therapy or susceptibility-based therapy to obtain acceptable cure rates.
Battulga A, Tserentogtokh T,
Matsuhisa T, Yamaoka Y and Keywords: Helicobacter pylori, antibiotic resistance, eradication therapy, empirical therapy, Mongolia
Oyuntsetseg K (2019) Initial Trials With
Susceptibility-Based and Empiric Abbreviations: Clari-TT, clarithromycin-triple therapy; CI, confidence interval; ELISA, ånzyme linked immunosorbent
Anti-H. pylori Therapies in Mongolia. assay; HpStAg test, H. pylori stool antigen test; ITT, intention-to-treat; M-BQT, modified bismuth quadruple therapy; MIC,
Front. Pharmacol. 10:394. minimum inhibitory concentrations; OR, odds ratio; PPI, proton pump inhibitor; PP, per-protocol; R, resistant; S, sensitive;
doi: 10.3389/fphar.2019.00394 SD, standard deviation; ST, sequential therapy.

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Byambajav et al. Drug Resistance of H. pylori and Treatment Response

INTRODUCTION Giemsa staining, and HpStAg test (SD. H. pylori Ag ELISA kit,
Korea). Patients with positive results in at least two of these tests
As in most developing countries, the prevalence of Helicobacter were eligible for enrollment.
pylori infection is high in Mongolia (Nyamdavaa, 2013) A second experiment was a multicenter study done between
with reported prevalence ranging of 80% among adults November 2013 and June 2014 in Ulaanbaatar and consisted of
(Matsuhisa et al., 2015; Khasag et al., 2018), 64% among 225 patients with dyspepsia who visited endoscopy departments
adolescents, and 65 and 100% among pediatric patients of one of three centers in Ulaanbaatar; University Hospital of
with gastric comorbidity (Go, 2013). Gastric cancer is a Mongolian National University of Medical Sciences, Ulaanbaatar
common problem in Mongolia; an age-standardized rate of Songdo Hospital, and The Third State Central Hospital. All
33.1 per 100,000, which is the second highest incidence in underwent gastroscopy with multiple biopsies for rapid urease
the world (International Agency for Research on Cancer; test, histology and H. pylori culturing. H. pylori strains were
GLOBOCAN2018). Information regarding H. pylori antibiotic isolated from 131 patients and further tested for antibiotic
resistance in Mongolia is scanty with a single prior study resistance. Metronidazole-based triple therapy was received the
reporting the resistance rates of 35.5% for clarithromycin, 68.4% patients with strains resistant to clarithromycin (n = 9). If
for metronidazole, 23% for amoxicillin, 25% for tetracycline, the H. pylori-isolates were resistance to metronidazole and
26.2% for erythromycin, and 14.5% for nitrofurantoin (Bolor- clarithromycin, but sensitive to amoxycillin (n = 21) levofloxacin-
Erdene et al., 2017). Here, we assessed the primary resistance of based triple therapy. These data were excluded from the study
H. pylori strains isolated from adults and compared antimicrobial because of few patient number (metronidazole-based triple
treatment efficacy of commonly used regimens in Mongolian therapy) and lacking the susceptibility test of levofloxacin
patients with dyspepsia. (levofloxacin-based triple therapy). Forty-six patients (29 women
and 17 men; mean age 39 years; range 24–54 years) were infected
with H. pylori susceptible to amoxicillin and clarithromycin
MATERIALS AND METHODS and were treated with susceptibility-based Clari-TT (n = 46)
consisting of 40 mg pantoprazole twice daily, 1 g amoxicillin
Patients, H. pylori Detection Tests, twice daily, and 500 mg clarithromycin twice daily for 10 days
Treatment, and Randomization (Table 1). PPIs were given a half-hour before breakfast and
This study was done between November 2013 and March the evening meal while antibiotics were given following these
2017 in Ulaanbaatar, the capital city of Mongolia where meals. In each group, an additional 2-week monotherapy with
more than half of the population of Mongolia lives. Study 40 mg pantoprazole once daily 7 days, followed by 20 mg
population consists of two groups. The initial study was to pantoprazole once daily 7 days following eradication therapy.
examine commonly used empiric therapies. The study was Cure rates were assessed using HpStAg test 28 days after the
done at the Department of Endoscopy at University Hospital termination of treatment.
of Mongolian National University of Medical Sciences between
March 2014 and March 2017 and consisted of 270 patients
with documented H. pylori infections (42 women and 89 men;
mean age 37 years; range 17–79 years). Using a computer- TABLE 1 | Helicobacter pylori eradication therapies.

generated number sequence, eligible H. pylori-infected patients Regimens Drugs Dose Daily Days
were randomly assigned to the Clari-TT group (n = 90): 40 mg
pantoprazole (KRKA.dd. Novo Mesto, Slovenia) twice daily, 1 g Empirical Clari-TTa Pantoprazole∗ 40 mg Twice 10
therapies (n = 90) Amoxicillin 1g Twice 10
amoxicillin (Astellas Pharma Europe BV, Netherlands) twice
Clarithromycin 500 mg Twice 10
daily, and 500 mg clarithromycin (Fromilid KRKA.dd. Novo
M-BQTb Pantoprazole∗ 40 mg Twice 10
Mesto, Slovenia) twice daily for 10 days, a M-BQT containing (n = 90) Bismuth 240 mg Twice 10
amoxicillin and clarithromycin-containing group (n = 90): tripotassium 1g Twice 10
40 mg pantoprazole twice daily, 240 mg bismuth tripotassium dicitrate 500 mg Twice 10
dicitrate (Astellas Pharma Europe BV, Netherlands) twice daily, Amoxicillin
Clarithromycin
1 g amoxicillin twice daily, and 500 mg clarithromycin twice
STc Pantoprazole∗ 40 mg Twice 5
daily for 10 days. The final group received 10-day ST group (n = 90) Amoxicillin 1g Twice 5
(n = 90) consisting of 40 mg pantoprazole twice daily and Followed by 40 mg Twice 5
1 g amoxicillin twice daily for 5 days, followed by 40 mg Pantoprazole 500 mg Twice 5
pantoprazole twice daily, 500 mg clarithromycin twice daily, Clarithromycin 500 mg Twice 5
Metronidazole
and 500mg metronidazole (PT. Otto Pharmaceutical Industries)
Susceptibility-based Pantoprazole∗ 40 mg Twice 10
twice daily for 5 additional days (Table 1). An independent
Clari-TT Amoxicillin 1g Twice 10
research assistant generated the computerized random number (n = 46) Clarithromycin 500 mg Twice 10
sequence. Before enrollment, the status of H. pylori infection
∗ An additional 2-week monotherapy with 40 mg pantoprazole once daily 7
was confirmed by a locally developed rapid urease test (Mon
days, followed by 20 mg pantoprazole once daily 7 days following eradication
HP test, developed at Mongolian National University of Medical therapy. a Clarithromycin-triple therapy, b modified bismuth quadruple therapy,
Sciences), histology with hematoxylin and eosin and modified c sequential therapy.

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Byambajav et al. Drug Resistance of H. pylori and Treatment Response

Exclusion criteria were: age < 18 years; previous H. pylori (EUCAST; available at www.eucast.org). Strains were considered
eradication therapy; consumption of PPI, histamine H2 - as resistant when the MIC was more than 0.125 mg/L for
receptor antagonists, bismuth and/or antibiotics, concomitant amoxicillin, >0.25 mg/L for clarithromycin, and >8 mg/L
anticoagulant, non-steroid anti-inflammatory drugs, or for metronidazole.
ketoconazole within the previous 4 weeks; patients with
allergic history to the medications used; previous surgery of Adverse Events and Compliance
the stomach, including endoscopic mucosal or submucosal At the end of the treatment, both side effects and therapeutic
resection for adenoma or early gastric cancer; patients with compliance were assessed by personal interview. The patients
peptic ulcer diseases and gastric cancer; the coexistence of serious were informed of the common adverse events of drugs before
concomitant illness (e.g., decompensated liver cirrhosis or kidney treatment initiation and were asked to record the symptoms
failure); alcohol abuse; pregnancy or lactation; Zollinger–Ellison during treatment in provided diaries. Adverse events were
syndrome; hematological disorders; and severe psychiatric or assessed according to a four-point scale system: 1 = none,
neurological disorders. 2 = mild (discomfort annoying but not interfering with daily
life), 3 = moderate (discomfort sufficient to interfere with daily
Antibiotic Susceptibility Testing life), and 4 = severe (discomfort resulting in discontinuation of
Experienced endoscopists collected gastric biopsy specimens eradication therapy). Compliance to treatment was considered
during each endoscopy session. Biopsy specimens for culture excellent if the patient took more than 90% of the medication,
were immediately placed in transport media containing 20% moderate if the patient took 70–90% of the medication, and poor
glycerol at −20◦ C, and stored at −80◦ C within a day of collection if the patient took less than 70% of medications.
until used for culture testing. For H. pylori culture, one antral
biopsy specimen was homogenized in saline and inoculated onto Statistical Analysis
Mueller Hinton II Agar medium (Becton Dickinson, Franklin All statistical analyses were performed using the SPSS software
Lakes, NJ, United States) supplemented with 7% horse blood (ver. 20.0, SPSS Inc., Chicago, IL, United States). Categorical
without antibiotics. The plates were incubated for up to 14 variables are reported as numbers and percentages and compared
days at 37◦ C under microaerophilic conditions (10% O2 , 5% using the chi-square test or Fisher’s exact test. Continuous
CO2 , and 85% N2 ). H. pylori isolates were identified on the variables are reported as means ± SD and were compared
basis of colony morphology, Gram staining results, and positive using t-tests. A multivariate logistic regression model including
reactions for oxidase, catalase, and urease. Isolated strains were age and sex was used to calculate the OR of the resistance
stored at −80◦ C in Brucella Broth (Difco, Franklin Lakes, places. The OR and 95% CI were used to estimate the risk.
NJ, United States) containing 10% dimethyl sulfoxide and Comparisons between patient groups were performed by using
10% horse serum. the t-test for unpaired data, the Chi-squared test and Tukey
The serial twofold agar dilution method was used to determine test as appropriate. The eradication rates with their 95% CI
the MIC of amoxicillin (Sigma Chemical Co., St Louis, MO, were calculated at both “ITT” and at “PP” analyses. At ITT,
United States), clarithromycin (Abbott Laboratories, Abbott all the enrolled patients were included, while at PP only
Park, IL, United States), and metronidazole (Sigma). Briefly, compliant patients who had done HpStAg test control were
bacteria were subcultured on Mueller Hinton II Agar medium considered. Two-tailed p-values of less than 0.05 were considered
(Becton Dickinson) supplemented with 10% defibrinated horse statistically significant.
blood. The bacterial suspension, adjusted to be equivalent to
a McFarland opacity standard of 3.0, was used to inoculate Ethics Statement
each plate. After 72 h incubation, the MIC of each antibiotic All procedures contributing to this work complied with the
was determined. Quality control was performed using H. pylori ethical standards of the relevant national and institutional
ATCC 43504. The resistance breakpoints were determined by committees on human experimentation and with the
the European Committee on Antimicrobial Susceptibility Testing Helsinki Declaration of 1975, as revised in 2008. The

TABLE 2 | Demographic and clinical characteristics of the enrolled patients with the Helicobacter pylori eradication therapies.

Characteristic Susceptibility-based Empirical therapies

Clari-TTa
Clari-TTa M-BQTb STc p-Value

Total patients 46 90 90 90 –
Age (years) 39 ± 15∗ 38.7 ± 15.6∗ 37 ± 11.8∗ 37.1 ± 12.7∗ 0.64
Sex (male/female) 17/29 28/62 42/48 39/51 0.08
Smoking habit (yes/no) 9/36 11/79 14/76 22/68 0.82
Alcohol consumption (yes/no or less than standard drink) 8/38 12/78 11/79 17/73 0.68

∗ mean ± SD, a Clarithromycin-triple therapy, b modified bismuth quadruple therapy, c sequential therapy.

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Byambajav et al. Drug Resistance of H. pylori and Treatment Response

study protocol was approved by the Institutional Ethical RESULTS

Committee of Mongolian National University of Medical
sciences (Ulaanbaatar, Mongolia) and Oita University Faculty Result of the Empirical Therapies
of Medicine (Yufu, Japan). Written informed consent A total of 270 H. pylori-infected patients were randomly assigned
was obtained from all participants prior to testing and to receive Clari-TT (n = 90), M-BQT (n = 90), and ST
prior to treatment. (n = 90). The data regarding the clinical characteristics of

FIGURE 1 | Flowchart of the patients in the study.

TABLE 3 | Helicobacter pylori eradication rates by ITT analysis and PP analysis fist-line therapies.

Therapy Susceptibility-based Empirical therapies P-value

Clari-TTa % (n)
Clari-TT %(n) M-BQTb %(n) STc %(n)

ITT analysis
H. pylori cure rate 89.1% (41/46) 71.1% (64/90) 87.8% (79/90) 67.8% (61/90) <0.0001
95%CI 86–98.2 61.7–80.5 81–94.6 58.1–77.5
P-value∗
Clari-TTa 0.021 – 0.071 0.988
M-BQTb 0.947 – 0.03
STc 0.008 – – –
PP analysis
H. pylori eradication rate 97.6% (41/42) 72.7% (64/88) 89.8% (79/88) 68.5% (61/89) <0.0001
95%CI 89.5–99.8 63.4–82 83.5–96.1 58.8–78.2
P-value∗
Clari-TTa 0.002 – 0.017 0.884
M-BQTb 0.853 – – 0.001
STc <0.0001 – – –
∗ P-values from pairwise comparison made by Tukey’s all-pairwise test. a Clarithromycin-triple therapy, b modified bismuth quadruple therapy, c sequential therapy.

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Byambajav et al. Drug Resistance of H. pylori and Treatment Response

TABLE 4 | Adverse effects reported by the patients during Helicobacter pylori therapy because of severe adverse effects. Therefore, the Clari-
eradication therapies.
TT, M-BQT, and ST groups had 88, 88, and 89 patients for
Adverse Susceptibility- Empirical therapies P-value PP analysis, respectively (Figure 1). Compliance to treatment
event based was excellent 98, 98, and 99% in Clari-TT, M-BQT, and ST
Clari-TTa Clari-TT M-BQTb STc groups, respectively.
Total number of patients
According to ITT analysis, cure rates for empiric therapies
(Number of patients with were 71.1% (95% CI = 61.7–80.5%) for Clari-TT, 87.8% (95%
mild/moderate/severe adverse events) CI = 81–94.6%) for M-BQT, and 67.8% (95% CI = 58.1–77.5%)
Nausea 2(0/2/0) 3(2/1/0) 0(0/0/0) 22(12/10/0) 0.0001 for ST; PP analysis results for these therapy were 72.7% (95%
Vomiting 0(0/0/0) 0(0/0/0) 0(0/0/0) 1(1/0/0) 0.38 CI = 63.4–82%), 89.8% (95% CI = 83.5–96.1%), and 68.5% (95%
Taste 1(1/0/0) 1(1/0/0) 2(1/0/1) 0(0/0/0) 0.36 CI = 58.8–78.2%), respectively (Table 3). Only M-BQT achieved
perversion acceptable or near acceptable cure rates (i.e., 87.8% ITT and
Abdominal pain 1(1/0/0) 4(2/2/0) 1(1/0/0) 5(2/3/0) 0.27 89.8% PP) (Table 3 and Figure 3).
Diarrhea 1(1/0/0) 5(3/2/0) 2(2/0/0) 1(1/0/0) 0.18 Overall 12.5, 4.5, and 22.2% patients in the Clari-TT, M-BQT,
Headache 0(0/0/0) 2(2/0/0) 1(1/0/0) 12(6/5/1) 0.0001 and ST groups complained of side effects (p = 0.02). The nausea
Skin rash 4(4/0/0) 3(2/1/0) 0(0/0/0) 3(3/0/0) 0.23 and headache were more commonly presented side effects in ST
Candida 2(2/0/0) 3(3/0/0) 1(1/0/0) 3(3/0/0) 0.56 than the Clari-TT and M-BQT (p = 0.0001) (Table 4).
Others 2(0/2/0) 0(0/0/0) 1(1/0/0) 1(1/0/0) 0.23
Total 9.5%(4/42) 12.5(11/88) 4.5%(4/89) 22.2%(20/90) 0.02
a Clarithromycin-triple b modified
Antimicrobial Susceptibility/Resistance
therapy, bismuth quadruple therapy,
c sequential therapy.
Susceptibility testing showed that overall resistance to all tested
antibiotics was high [e.g., 11 (8.4%) resistant to amoxicillin,
49 (37.4%) resistant to clarithromycin, and 97 (74%) to
the patients are summarized in Table 2. All subjects treated metronidazole] (Figure 2). Only 20 (15.3%) were susceptible to
were included in the ITT analysis for H. pylori eradication. all three antibiotics and 40 (30.5%) were resistant to at least two
A total of 265 patients completed the study. Two patients in antibiotics. One (0.8%) isolate showed resistance to amoxicillin
the Clari-TT group and one patient in the M-BQT group did and clarithromycin and six (4.8%) were R, to all three antibiotics
not complete follow-up HpStAg ELISA testing. One patient in (Table 5). The proportion of strains resistant to metronidazole
the M-BQT group and one patient in the ST group interrupted was lower in the aged <29 years and >60 years groups compared

FIGURE 2 | Distribution of antibiotic MIC values. (A) Amoxicillin. (B) Metronidazole. (C) Clarithromycin.

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Byambajav et al. Drug Resistance of H. pylori and Treatment Response

FIGURE 3 | Helicobacter pylori eradication rates of the treatment groups according to the ITT and PP analysis. ITT – intention-to-treat; PP – per protocol; Clar-TT –
clarithromycin-triple therapy; M-BQT – modified bismuth quadruple therapy; ST – sequential therapy.

to the other age groups (p = 0.03). Resistances to the other patients enrolled, 37 (80.3%) were non-smokers and 38 (81.6%)
two antibiotics and multidrug resistance were independent of either did not consume alcohol or took less than standard
age (Table 6). drink/day (Table 2). All enrolled were included in the ITT
analysis. A total of 42 patients completed susceptibility-based
Result of the Susceptibility-Based Clari-TT and four did not receive a confirmation of cure HpStAg
ELISA test. The cure rates were: ITT 89.1% (95% CI = 86–
Therapy
98.2%) and PP 97.6% (95% CI = 89.5–99.8%), respectively
Forty-six patients (29 women and 17 men; mean age 39
(Table 3). Total of 9.5% patients in the susceptibility-based
years; range 24–54 years) received susceptibility-based Clari-
Clari-TT regimen had side effects (Table 4). The cure rates
TT. Although 78 strains were sensitive for both amoxicillin and
for susceptibility-based Clari-TT were significantly greater than
clarithromycin, 32 subjects refused to participate. Among 46
those when the same regime was used as an empiric therapy
(Table 3 and Figure 3).
TABLE 5 | Multidrug resistance.

Helicobacter pylori Antimicrobial S or R to multidrug DISCUSSION

susceptibility testing

Helicobacter pylori infection is an infectious disease and

Amoxicillin Clarithromycin Metronidazole N (%)
it has been suggested that ideal regimens should be able
Sa S S 20 (15.3) S to multidrug to cure more than 95% of cases adherent to the regimen.
91 (69.5%) According to one classification (Graham et al., 2007), the
S S Rb 58 (44.3) efficacy of H. pylori eradication regimens is considered
S R S 11 (8.4) as: A = excellent (>95% PP eradication rate), B = good
R S S 2 (1.5) (90–95%), C = fair (85–89%), D = poor (81–84%), and
R R R 6 (4.8) R to multidrug F = unacceptable (≤80% PP eradication rate). In Mongolia,
40 (30.5%)
empiric therapy with Clari-TT and ST regimens was
R R S 1 (0.8)
unacceptable as empiric therapies. However, susceptibility-
R S R 2 (1.5)
based therapy and empiric M-BQT were classified as
S R R 31 (23.7)
excellent and good regimens with PP cure rates of 98 and
a S-S, b R-R. 90%, respectively.

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TABLE 6 | Relationship between age and antibiotic resistance of Helicobacter pylori.

Antimicrobial susceptibility testing result Age groups

≤29(38) n (%) 30–39(35) n (%) 40–49(25) n (%) 50–59(17) n (%) ≥60 (16) n (%) P-value

R to multiple drugs (40) 6 (15.8) 14 (40) 10 (40) 4 (23.5) 6 (37.6) 0.126

Metronidazole-Ra (97) 21 (55.3) 29 (82.9) 21 (84) 16 (94.1) 10 (62.5) 0.03
Amoxicillin-R (11) 5 (13.2) 1 (2.9) 3 (12) 1 (5.9) 1 (6.3) 0.53
Clarithromycin-R (49) 11 (28.9) 14 (40) 12 (48) 4 (23.5) 8 (50) 0.29
aR – R.

In Mongolia, there are no previous data H. pylori cure reported that bismuth impeded proton entry into the organisms
rates. The high prevalence of clarithromycin and metronidazole potentially impairing their ability to respond to acid and
resistance in Mongolia undermined the efficacy of empiric Clari- enhancing the efficacy of growth-dependent antibiotics (Marcus
TT and ST (Rossum, 1999; Janssen et al., 2001; Horvath et al., et al., 2015). Recent studies have suggested that tetracycline
2012; Kate et al., 2013; Yoon et al., 2013; Zullo et al., 2013). can be replaced by amoxicillin 1 g t.i.d. with excellent
H. pylori resistance to metronidazole was very high (74%) in results in highly resistant populations (Chen et al., 2016;
Mongolia which is consistent with other studies from developing Graham et al., 2018a).
countries, possibly owing to the common use of metronidazole to The limitations of this study include the fact that it conducted
treat parasitic infections, periodontal, and gynecological diseases on a small sample size, taken from a geographically limited
in developing countries. Among other Asia-Pacific countries, population in Ulaanbaatar, Mongolia. Other limitations
China, Vietnam, Bhutan, and Bangladesh and Nepal had the included use of low dose PPI therapy (i.e., pantoprazole
highest prevalence of metronidazole resistance (61, 72, 83, 84, 40 mg is equivalent to 9 mg of omeprazole) (Graham et al.,
and 88%, respectively) (Kuo et al., 2017). Loss of penicillin- 2018b). Recent recommendations recommend double-dose PPI
binding protein is known to be associated with amoxicillin which is equivalent to at least 40 mg of omeprazole/dose.
resistance (Gerrits et al., 2002). H. pylori resistance to amoxicillin All recent recommendations also recommend that the
in Mongolia was higher (8.4%) than in most other countries duration of therapy be 14 days (Malfertheiner et al., 2016;
(Horiki et al., 2009; Caliskan et al., 2015; Miftahussurur and Graham et al., 2018a). Subsequent studies to compare 10
Yamaoka, 2015; Boyanova et al., 2016). However, increasing and 14 day therapies are needed. In addition, in Japan,
amoxicillin primary resistance rates have been reported in the dosage of clarithromycin is lower (i.e., 200 in stead of
South Korea (7.1–18.5%) (Lee et al., 2013). In our previous 500 mg/dose) (Lee, 2014) and studies using this lower dose
study (Bolor-Erdene et al., 2017), we had also reported very in Mongolia might also result in improved compliance due to
high rate of amoxicillin resistance. We think several possibilities reduced side effects.
as follows; poor compliances of drug regulation policy (i.e.,
no prescription is required) and amoxicillin is one of the
most commonly prescribed antibiotics for patients suffer from
respiratory tract, ear, nose, and throat infection, which is a leading CONCLUSION
cause of population morbidity with 1579.9 cases per 10,000
Helicobacter pylori resistance rate to metronidazole,
population (Health indicators of Mongolia for WPRO, WHO
clarithromycin, and amoxicillin are high in Mongolia. These
database. [Internet]. 2017. Available from: http://www.chd.mohs.
initial studies have shown that highly successful therapy is
mn). Amoxicillin is the first-line treatment for these infections,
possible using empiric bismuth quadruple therapies and
and combination use of clarithromycin has increased recently.
susceptibility-based therapy. Subsequent studies are needed to
The Maastricht (Malfertheiner et al., 2016) and Toronto
identify the optimum drugs, doses, and duration of therapy to
Consensus (Fallone et al., 2016) recommend 14-day bismuth,
reliably cure the majority of cases treated in Mongolia.
tetracycline, metronidazole, PPI quadruple therapy M-BQT,
or susceptibility-based therapy be used in regions with high
clarithromycin resistance. The results from this study provided
evidence that our modified bismuth quadruple and susceptibility- AUTHOR CONTRIBUTIONS
based therapies were more effective than Clari-TT and ST
in a country with high resistance for clarithromycin and T-OB, KO, NB, GC, and YY conceived and designed the study.
metronidazole. BQT is a 20-year-old regimen that consists of T-OB, KO, AB, TT, TM, and YY contributed by collecting
PPIs plus bismuth salt, tetracycline, and metronidazole (Der samples. AE, BG, and DE provided H. pylori stool antigen test,
Hulst et al., 1996). We used a M-BQT due to unavailability of microbiological, and histological assessment. T-OB, KO, and YY
tetracycline in Mongolia. Recently, Dore et al. (2016) reported contributed to analysis and interpretation. T-OB, DD, TS, and GS
that addition of bismuth to Clari-TT increase treatment efficacy enrolled and treated the patients and collected data. T-OB, KO,
by 30–40%. The mechanisms of bismuth in the eradication GC, NB, and YY drafted the manuscript. All authors read and
of H. pylori remain unclear. The most recent in vitro study approved the final manuscript.

Frontiers in Pharmacology | www.frontiersin.org 7 April 2019 | Volume 10 | Article 394

Byambajav et al. Drug Resistance of H. pylori and Treatment Response

FUNDING (JST) (YY). BG is a Ph.D. student supported by The Japanese

Government (Monbukagakusho: MEXT) Scholarship Program
This work was supported in part by the Grants-in-Aid for for 2014.
Scientific Research from the Ministry of Education, Culture,
Sports, Science, and Technology (MEXT) of Japan (15H02657,
16H06279, 16H05191, and 18KK0266) (YY). This work was also ACKNOWLEDGMENTS
supported by the Japan Society for the Promotion of Science
(JSPS) Institutional Program for Young Researcher Overseas We wish to thank sponsor companies (KRKA, DENK PHARMA,
Visits (YY), and the Strategic Funds for the Promotion of Science MONFA, ASTELLAS, MOH-HP, and ONOSH). We also thank
and Technology from Japan Science and Technology Agency Dr. David Y. Graham for his helpful comments.

REFERENCES Aliment. Pharmacol. Ther. 36, 534–541. doi: 10.1111/j.1365-2036.2012.

05229.x
Bolor-Erdene, M., Namdag, B., Yamaoka, Y., and Jav, S. (2017). Antibiotic Janssen, M., Van Oijen, A., Verbeek, A., Jansen, J., and De Boer, W.
resistance of Helicobacter pylori in mongolia. J. Infect. Dev. Ctries 11, 887–894. (2001). A systematic comparison of triple therapies for treatment of
doi: 10.3855/jidc.8619 Helicobacter pylori infection with proton pump inhibitor/ranitidine bismuth
Boyanova, L., Gergova, G., Evstatiev, I., Spassova, Z., Kandilarov, N., Yaneva, P., citrate plus clarithromycin and either amoxicillin or a nitroimidazole.
et al. (2016). Helicobacter pylori resistance to six antibiotics by two breakpoint Aliment. Pharmacol. Ther. 15, 613–624. doi: 10.1046/j.1365-2036.2001.
systems and resistance evolution in bulgaria. Infect. Dis. 48, 56–62. doi: 10.3109/ 00974.x
23744235.2015.1082035 Kate, V., Kalayarasan, R., and Ananthakrishnan, N. (2013). Sequential therapy
Caliskan, R., Tokman, H. B., Erzin, Y., Saribas, S., Yuksel, P., Bolek, B. K., versus standard triple-drug therapy for Helicobacter pylori eradication: a
et al. (2015). Antimicrobial resistance of Helicobacter pylori strains systematic review of recent evidence. Drugs 73, 815–824. doi: 10.1007/s40265-
to five antibiotics, including levofloxacin, in Northwestern Turkey. 013-0053-z
Rev. Soc. Bras. Med. Trop. 48, 278–284. doi: 10.1590/0037-8682-0027- Khasag, O., Boldbaatar, G., Tegshee, T., Duger, D., Dashdorj, A., Uchida, T., et al.
2015 (2018). The prevalence of Helicobacter pylori infection and other risk factors
Chen, Q., Zhang, W., Fu, Q., Liang, X., Liu, W., Xiao, S., et al. (2016). among mongolian dyspeptic patients who have a high incidence and mortality
Rescue therapy for Helicobacter pylori eradication: a randomized non- rate of gastric cancer. Gut Pathog. 10:14. doi: 10.1186/s13099-018-0240-2
inferiority trial of amoxicillin or tetracycline in bismuth quadruple Kuo, Y.-T., Liou, J.-M., El-Omar, E. M., Wu, J.-Y., Leow, A. H. R., Goh, K. L., et al.
therapy. Am. J. Gastroenterol. 111, 1736–1742. doi: 10.1038/ajg. (2017). Primary antibiotic resistance in Helicobacter pylori in the Asia-Pacific
2016.443 region: a systematic review and meta-analysis. Lancet Gastroenterol. Hepatol. 2,
Der Hulst, R. W., Keller, J. J., Rauws, E. A., and Tytgat, G. N. (1996). 707–715. doi: 10.1016/S2468-1253(17)30219-4
Treatment of Helicobacter pylori infection: a review of the world Lee, J. W., Kim, N., Kim, J. M., Nam, R. H., Chang, H., Kim, J. Y., et al. (2013).
literature. Helicobacter 1, 6–19. doi: 10.1111/j.1523-5378.1996.tb0 Prevalence of primary and secondary antimicrobial resistance of Helicobacter
0003.x pylori in Korea from 2003 through 2012. Helicobacter 18, 206–214. doi: 10.1111/
Dore, M. P., Lu, H., and Graham, D. Y. (2016). Role of bismuth in improving hel.12031
Helicobacter pylori eradication with triple therapy. Gut 65, 870–878. doi: 10. Lee, S.-Y. (2014). Current progress toward eradicating Helicobacter pylori in east
1136/gutjnl-2015-311019 Asian countries: differences in the 2013 revised guidelines between China,
Fallone, C. A., Chiba, N., van Zanten, S. V., Fischbach, L., Gisbert, J. P., Hunt, R. H., Japan, and South Korea. World J. Gastroenterol. 20, 1493–1502. doi: 10.3748/
et al. (2016). The toronto consensus for the treatment of Helicobacter pylori wjg.v20.i6.1493
infection in adults. Gastroenterology 151, 51–69.e14. doi: 10.1053/j.gastro.2016. Malfertheiner, P., Megraud, F., O’morain, C., Gisbert, J., Kuipers, E., Axon, A.,
04.006 et al. (2016). Management of Helicobacter pylori infection—the maastricht
Gerrits, M., Schuijffel, D., Van Zwet, A., Kuipers, E., Vandenbroucke-Grauls, C., V/Florence consensus report. Gut 66, 6–30. doi: 10.1136/gutjnl-2016-31
and Kusters, J. (2002). Alterations in penicillin-binding protein 1A confer 2288
resistance to β-lactam antibiotics in Helicobacter pylori. Antimicrob. Marcus, E. A., Sachs, G., and Scott, D. R. (2015). Colloidal bismuth subcitrate
Agents Chemother. 46, 2229–2233. doi: 10.1128/AAC.46.7.2229-2233. impedes proton entry into Helicobacter pylori and increases the efficacy of
2002 growth-dependent antibiotics. Aliment. Pharmacol. Ther. 42, 922–933. doi: 10.
Go, G. (2013). Some aspect of diagnostic and therapeutic improvements of 1111/apt.13346
chronic gastroduodenitis in children. J. Mongolian Study Group H. Pylori Matsuhisa, T., Yamaoka, Y., Uchida, T., Duger, D., Adiyasuren, B., Khasag, O.,
1:14. et al. (2015). Gastric mucosa in mongolian and japanese patients with gastric
Graham, D. Y., Dore, M. P., and Lu, H. (2018a). Understanding treatment cancer and Helicobacter pylori infection. World J. Gastroenterol. 21, 8408–8417.
guidelines with bismuth and non-bismuth quadruple Helicobacter pylori doi: 10.3748/wjg.v21.i27.8408
eradication therapies. Expert Rev. Anti Infect. Ther. 16, 679–687. doi: 10.1080/ Miftahussurur, M., and Yamaoka, Y. (2015). Appropriate first-line regimens to
14787210.2018.1511427 combat Helicobacter pylori antibiotic resistance: an asian perspective. Molecules
Graham, D. Y., Lu, H., and Dore, M. P. (2018b). Relative potency of proton-pump 20, 6068–6092. doi: 10.3390/molecules20046068
inhibitors, Helicobacter pylori therapy cure rates, and meaning of double-dose Nyamdavaa, T. (2013). The influence of sanitary hygienic conditions to
PPI. Helicobacter 24:e12554. doi: 10.1111/hel.12554 the prevalence of H.pylori infection and treatment features of the
Graham, D. Y., Lu, H., and Yamaoka, Y. (2007). A report card to grade Helicobacter H. pylori associated disease in mongolia. J. Mongolian Study Group
pylori therapy. Helicobacter 12, 275–278. doi: 10.1111/j.1523-5378.2007. H. Pylori 1:18.
00518.x Rossum, L. V. (1999). Evaluation of treatment regimens to cure Helicobacter pylori
Horiki, N., Omata, F., Uemura, M., Suzuki, S., Ishii, N., Iizuka, Y., et al. (2009). infection—a meta-analysis. Aliment. Pharmacol. Ther. 13, 857–864. doi: 10.
Annual change of primary resistance to clarithromycin among Helicobacter 1046/j.1365-2036.1999.00542.x
pylori isolates from 1996 through 2008 in Japan. Helicobacter 14, 438–442. Yoon, H., Lee, D. H., Kim, N., Park, Y. S., Shin, C. M., Kang, K. K., et al.
doi: 10.1111/j.1523-5378.2009.00714.x (2013). Meta-analysis: is sequential therapy superior to standard triple therapy
Horvath, A., Dziechciarz, P., and Szajewska, H. (2012). Meta-analysis: for Helicobacter pylori infection in Asian adults? J. Gastroenterol. Hepatol. 28,
sequential therapy for Helicobacter pylori eradication in children. 1801–1809. doi: 10.1111/jgh.12397

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Byambajav et al. Drug Resistance of H. pylori and Treatment Response

Zullo, A., Hassan, C., Ridola, L., De Francesco, V., and Vaira, D. (2013). Copyright © 2019 Byambajav, Bira, Choijamts, Davaadorj, Gantuya, Sarantuya,
Standard triple and sequential therapies for Helicobacter pylori eradication: Sarantuya, Enkhtsetseg, Erdenetsogt, Battulga, Tserentogtokh, Matsuhisa, Yamaoka
an update. Eur. J. Intern. Med. 24, 16–19. doi: 10.1016/j.ejim.2012. and Oyuntsetseg. This is an open-access article distributed under the terms of
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