Is culture necessary before first-line treatment for Helicobacter pylori infection?
Is culture necessary before first-line treatment for Helicobacter pylori infection?
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幽门螺杆菌感染一线治疗前是否需要培养？
DOI：
10.2169/internalmedicine.50.5135
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发表时间：
2011
影响因子：
1.2
通讯作者：
J. Gisbert
中科院分区：
文献类型：
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作者：
J. Gisbert
致编辑我们饶有兴趣地阅读了Wenzhen等人的文章（1），其结论是“在幽门螺杆菌感染的一线治疗之前，抗菌药物敏感性测试是必要的”。然而，到目前为止的所有共识会议都建议，在处方第一次（甚至第二次）根除治疗后进行培养是不必要的，并且评估H.在临床实践中，只有在第二次治疗失败后，才可能提示幽门螺杆菌对抗生素敏感。在这方面，我们想强调在一线治疗H.幽门螺杆菌感染（3，4）：1）培养意味着进行内窥镜检查，这有几个缺点：它令人烦恼，它不是没有风险，并且，由于内窥镜检查中心的需求不断增加，它涉及延长的等待时间。2)培养是昂贵的，这在一定程度上是由于程序本身的成本，但主要是由于获得活检标本所必需的相关内窥镜检查的成本。3)培养是一项耗时的工作，正如H.幽门螺杆菌是一种相当“挑剔”的细菌。4)文化并不总是可以在常规的基础上。5)细菌培养的敏感性不是100%。事实上，即使在治疗试验中通常遇到的最佳条件下，培养敏感性也<90%。6)临床实践中的抗生素敏感性试验仅产生关于少数抗生素的有用信息：克拉霉素和不太清楚的甲硝唑（因为对阿莫西林和四环素的耐药性极低）。7)即使知道H.幽门螺杆菌，根除率不能达到100%，因为通过体外抗生素敏感性观察体内结果往往令人失望。8)最后，使用较新且不同于标准三联方案的经验性一线治疗（如“序贯”和“伴随”方案）获得了相对较高的根除率（90%）（5）。综上所述，H.幽门培养是一种侵入性的、耗时的方法，提供相当低的灵敏度，需要大量的成本，并且在实践中，测试很少的抗生素，对患者的管理的贡献值得怀疑（4）。患者是否应该接受上消化道内镜检查进行细菌培养仍然是一个有争议的问题[4]。显然，H.幽门螺杆菌培养在流行病学和药理学研究领域都保持不变。此外，在对H.幽门螺杆菌治疗，目的是研究抗生素耐药性的流行，并评估这种耐药性对治疗效果的影响。
To the Editor We read with interest the article by Wenzhen et al (1), concluding that “antimicrobial susceptibility testing is necessary before first-line treatment for Helicobacter pylori infection”. However, it has been recommended ― in all the Consensus Conferences up to now (2)― that performing culture after prescribing a first (or even a second) eradication treatment is not necessary and that assessing H. pylori sensitivity to antibiotics in clinical practice may be suggested only after failure of the second treatment. In this respect, we would like to emphasize some limitations of performing culture systematically before first-line treatment for H. pylori infection (3, 4): 1) Culture implies the performance of endoscopic exploration, which has several disadvantages: it is annoying, it is not free from risk, and, since endoscopy centres have been subjected to increasing demand, it involves prolonged waiting times. 2) Culture is expensive, due somewhat to the cost of the procedure itself, but mainly due to the costs of the associated endoscopy which is necessary to obtain biopsy specimens. 3) Culture is time-consuming, as H. pylori is a rather “fastidious” bacterium. 4) Culture is not always available on a routine basis. 5) The sensitivity of bacterial culture is not 100%. Indeed, even in the optimal conditions usually encountered in therapeutic trials, culture sensitivity is <90%. 6) Antibiotic susceptibility testing in clinical practice yields useful information only regarding a few antibiotics: clarithromycin and, less clearly, metronidazole (as resistance to amoxicillin and tetracycline is extremely low). 7) Even knowing the susceptibility of H. pylori, eradication rates do not achieve 100%, as the results observed in vivo by following in vitro susceptibility to antibiotics are often disappointing. 8) Finally, relatively high eradication rates ( 90%) have been obtained with newer and ―different from the standard triple regimens― empirical first-line treatments, such as the “sequential” and the “concomitant” regimens (5). In summary, H. pylori culture is an invasive, timeconsuming method, offering quite low sensitivity, requiring significant cost, and which, in practice, tests very few antibiotics, with a questionable contribution to the management of patients (4). Whether patients should undergo an upper endoscopy for bacterial culture remains a debatable matter (4). Obviously, the importance of H. pylori culture remains unaltered both in epidemiological and pharmacological research fields. Furthermore, it would be recommendable that culture is systematically performed even before first eradication treatment in specialized centres with interest in H. pylori treatment, with the intention to study the prevalence of antibiotic resistances and also to evaluate the influence of such resistances on the efficacy of treatment.