a Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam; b Department of Intensive Care, Medical Centre Leeuwarden-Zuid, Leeuwarden; c Department of Gastroenterology, Academic Medical Center, Amsterdam; d Department of Internal Medicine and Gastroenterology, Kennemer Gasthuis, Haarlem; e Department of Medical Microbiology, Academic Medical Center, Amsterdam and f Department of Gastroenterology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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Abstract |
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Introduction |
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Materials and methods |
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Six volunteers with H. pylori infection, as detected by LARA [13C]urea breath test and serology were studied. They took the topical PTA antibiotics four times daily with food for 7 days. The volunteers did not use proton pump inhibitors or other medication.
Detection of H. pylori
Urea breath test. A LARA [13C]urea breath test (Alimenterics, Morris Plains, NJ, USA) was performed immediately after admission to the ICU and institution of mechanical ventilation.4 Repeated tests were done on the third and every seventh day until discharge from the ICU. Patients were not followed up after discharge from the ICU. The volunteers performed a LARA [13C]urea breath test before treatment and 1 day and 8 weeks after cessation of treatment. Previously, we have shown the LARA [13C]urea breath test to be an easy and reliable method of detecting H. pylori.4,5
Serology. IgG antibodies against H. pylori were detected by enzyme-linked immunosorbent assay (HM-CAP ELISA Enteric Products Inc., Stony Brook, NY, USA). A cut-off of 1.8 U/L was used. Sera were drawn immediately after ICU admission, on the third day and every seventh day thereafter.
Culture and MICs
Upper gastrointestinal endoscopy was performed within 6 h after ICU admission before any antibiotic treatment was given. Antrum and corpus biopsies were stored in phosphate-buffered saline and kept in a refrigerator until bacteriological culturing within 12 h. Cultures were prepared by rubbing biopsy specimens on the surface of horse blood agar plates (5% defibrinated horse blood Columbia agar base (Oxoid CM 331); Unipath, Basingstoke, UK) and horse blood agar plates containing Dent supplement (Unipath). Cultures were incubated at 35°C for 10 days in a microaerophilic atmosphere (5% O2, 10% CO2 and 85% N2). H. pylori was identified on the basis of typical colony morphology, characteristic appearance on Gram staining, and positive urease, oxidase and catalase tests. The susceptibility to antibiotics was assessed by Etest (AB Biodisk, Solna, Sweden) on horse blood agar plates in a microaerophilic atmosphere according to the manufacturer's instructions. Susceptibility to polymyxin E was assessed by agar diffusion on horse blood agar using tablets containing 150 µg polymyxin (Neo-Sensitabs, Rosco, Denmark).
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Results |
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In all six volunteers who ingested PTA but who did not receive cefotaxime, the urea breath test converted to negative within 7 days of treatment. However, a repeated test after 8 weeks showed eradication in only one of six volunteers.
Eleven unique strains of H. pylori obtained from seven critically ill patients were cultured and their susceptibility to antibiotics was determined (Table).
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Discussion |
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In general, topical treatment of H. pylori may have advantages over systemic treatment. Non-absorbable antibiotics lack systemic effects and may therefore lead to lesser side effects and greater patient compliance. PTA are non-absorbable antibiotics that are effective in decontaminating the digestive tract of potentially pathogenic microorganisms.7 The Gram-positive flora is not affected by these antibiotics and therefore colonization resistance remains intact. The widespread use of these antibiotics in critically ill patients has not been associated with emergence of antimicrobial resistance.810 Previously, we found that the presence of H. pylori infection in critically ill patients was associated with greater severity of gastric mucosal lesions.1 In the present study we showed that H. pylori is suppressed effectively by SDD antibiotics. These findings may explain why stress ulceration was virtually absent in a group of patients treated with SDD.2
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Notes |
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References |
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2 . Zandstra, D. F. & Stoutenbeek, C. P. (1994). The virtual absence of stress-ulceration related bleeding in ICU patients receiving prolonged mechanical ventilation without any prophylaxis. Intensive Care Medicine 20, 33540.[ISI][Medline]
3 . Van der Voort, P. H. J., Van der Hulst, R. W. M., Zandstra, D. F., Geraedts, A. A. M. & Tytgat, G. N. J. (1998). Suppression of Helicobacter pylori infection under selective decontamination of the digestive tract. Intensive Care Medicine 24, Suppl. 1, S7.
4 . Van der Voort, P. H. J., van der Hulst, R. W. M., Zandstra, D. F., Geraedts, A. A. M. & Tytgat, G. N. J. (1999). Detection of Helicobacter pylori in mechanically ventilated intensive care patients: the LARA-13C-urea breath test and serology. Clinical Intensive Care 10, 915.
5 . Van der Hulst, R. W. M., Lamouliatte, H., Megraud, F. & Tytgat, G. N. J. (1999). Laser-assisted ratio analyser 13C-urea breath testing for the detection of H. pylori infection: a prospective diagnostic European multicenter study. Alimentary Pharmacology and Therapeutics 13, 11717.[ISI][Medline]
6 . Peterson, W. L., Graham, D. Y., Marshall, B., Blaser, M. J., Genta, R. M., Klein, P. D. et al. (1993). Clarithromycin as monotherapy for eradication of Helicobacter pylori: a randomized, double-blind trial. American Journal of Gastroenterology 88, 18604.[ISI][Medline]
7 . Stoutenbeek, C. P., van Saene, H. K. F., Miranda, D. R. & Zandstra, D. F. (1984). The effect of selective decontamination of the digestive tract on colonization and infection rate in multiple trauma patients. Intensive Care Medicine 10, 18592.[ISI][Medline]
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D'Amico, R. D., Pifferi, S., Leonetti, C., Torri, V., Tinazzi, A. & Liberati, A. (1998). Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomised controlled trials. British Medical Journal 316, 127585.
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10 . Tetteroo, G. W. M., Wagenvoort, J. H. T. & Bruining, H. A. (1994). Bacteriology of selective decontamination: efficacy and rebound colonization. Journal of Antimicrobial Chemotherapy 34, 13948.[Abstract]
Received 2 March 2000; returned 15 May 2000; revised 30 June 2000; accepted 19 July 2000