利用胃液分析引導幽門螺旋桿菌的第一線殺菌治療

The first line Helicobacter pylori eradication guiding by using gastric juice analysis

鄭光宏(Guang-Hong Jheng)

指導教授 ： 吳登強

高雄醫學大學/醫學院/臨床醫學研究所碩士班/碩士(2018年)

摘要

研究背景與目的：
幽門螺旋桿菌會造成胃發炎、消化性潰瘍、高度分化不良及胃癌，因此幽門螺旋桿菌已被世界衛生組織WHO認定是胃癌的危險因子之一，根據2017高醫與高榮團隊共同發表的一篇論文提到亞太地區臨床醫師實際使用殺菌藥物組合的調查，傳統七天三合一療法(proton pump inhibitor，amoxicillin，clarithromycin)的組合因藥物種類、顆數跟天數最少、副作用比較少，仍然是最多醫師選擇的，高達50.4%[1]，不過殺菌率因為許多因素如抗藥性菌種增加、病人服藥順從性不佳、病人的CYP2C19之多基因型影響氫離子幫浦阻斷劑的作用、IL-1Beta-511多基因型影響胃中酸鹼值等，使得殺菌成功率逐年下降，因此為了增加第一線殺菌的成功率及讓病人有機會選擇最單純最好配合服藥的七天三合一療法治療，我們不僅使用胃液分析幽門螺旋桿菌的有無，也利用PCR-RFLP(polymerase chain reaction-restriction fragment length polymorphism)及DNA定序的方法去分辨出幽門螺旋桿菌對於clarithromycin及levofloxacin是否具有抗藥性，也利用胃液分析病人的CYP2C19及Interleukin-1Beta 511之多基因型，讓臨床醫師在第一線殺菌用藥前，選擇更適當的抗生素去執行殺菌的治療，提高幽門螺旋桿菌的殺菌成功率。
研究方法：
收案時間為民國103年3月到民國106年10月，從123個經由胃液分析得知幽門螺旋桿菌是陽性且還未接受治療的病人中，將其分成兩組，實驗組62個病人是根據胃液分析的抗藥性結果去決定使用殺菌藥組合，對照組則是一律使用傳統七天三合一療法（rabeprazole 20mg早晚各一顆，amoxicillin 500mg早晚各兩顆，clarithromycin 500mg早晚各一顆）治療，再使用碳13吹氣檢測追蹤殺菌是否成功，我們經由胃鏡檢查的同時採集胃液，將胃液進行分析化驗，萃取出DNA後，先得知是否有幽門螺旋桿菌，接下來再檢驗是否有clarithromycin的抗藥性(23srRNA的點突變)，如果有clarithromycin抗藥性的話，再檢驗是否有levofloxacin的抗藥性(GyrA point mutation)，另外也有分析病人的CYP2C19Interleukin-1Beta 511之多基因型提供影響治療成功率的參考因素，本實驗結果是使用SPSS第22版進行統計分析。
結果：
在實驗組當中用胃液引導治療的62位病人，殺菌成功率是88.7%（55/62），實驗組的病人當中有49位病人對於clarithromycin是沒有抗藥性的，因為clarithromycin sensitive所以採用第一線傳統七天三合一療法，根除率是87.8%（43/49），其餘13位病人對clarithromycin有抗藥性，所以接續檢驗levofloxacin的抗藥性之後，8位病人對levofloxacin有抗藥性，5位病人沒有抗藥性，除菌率分別為100%（8/8）與 80%（4/5）。對照組當中，全部61位病人都直接使用傳統七天三合一療法，殺菌成功率為75.4%（46/61），兩組的殺菌率經卡方檢定分析後，P<0.05有達到統計學差異，CYP2C19及IL-1B-511多基因型對於殺菌率的影響，經過分析之後，發現CYP2C19 PM type比non-PM type殺菌率高，non-HomEM比HomEM殺菌率高，IL-1B-511中T/T type比non-T/T type殺菌率高，non-C/C type比C/C type殺菌率高。
結論：
根據實驗結果，利用胃液分析可以快速得知幽門螺旋桿菌是否存在以及對抗生素是否有抗藥性以及CYP2C19、Interleukin-1Beta 511之多基因型，引導臨床醫師使用正確的抗生素組合及氫離子幫浦阻斷劑執行殺菌治療，此方法方便快速，操作執行性高，明顯提高第一線幽門螺旋桿菌的殺菌成功率，且較不受CYP2C19多基因型影響，尤其針對雙重抗藥性的菌株，也可得到更好的殺菌結果。

關鍵字

胃液 ； 幽門螺旋桿菌 ； 第一線

並列摘要

Object:

Helicobacter pylori(H.pylori) can cause gastritis, peptic ulcer, high grade dysplasia and even gastric cancer. Thus, H.pylori has been identified one risk factor of causing gastric cancer by World Healthy Organization(WHO). According to one study by KMUH and VGHKS, 7-day clarithromycin-based standard triple therapy still the first choice by most physicians(50.4%)[1]. The standard triple therapy had advantage of good compliance, shortest therapy durations and less side effect than other regimens. The 7-day clarithromycin-based standard triple therapy including proton pump inhibitor, amoxicillin, clarithromycin for first line eradication rate has been decreasing due to increasing rate of antibiotic resistance, poor compliance of drug, polymorphism of CYP2C19 gene relating to proton pump inhibitor metabolism, IL-1beta-511 relating to pH value in stomach. For enhancing eradication rate of standard 7-day triple therapy, we not only use gastric juice analysis for examining if existence of H.pylori but finding out resistance to clarithromycin and levofloxacin by PCR-RFLP(polymerase chain reaction-restriction fragment length polymorphism) and DNA sequencing. In addition, we analyze polymorphism of CYP2C19 and Interleukin-1Beta 511 gene by gastric juice analysis. Providing the more effective first line regimen for clinicians to treat patient within H.pylori infection.

Method:

The study had collected 123 patients who had positive finding with H.pylori confirmed by gastric juice analysis and not receiving eradication yet from March 2014 to October 2016. We divided these patients into two groups. Experimental group composing of 62 patients, choosing proper regimen for H.pylori eradication by gastric juice analysis. Control group composing of 61 patients, using standard 7-day triple therapy(rabeprazole 20mg 1#bid，amoxicillin 500mg 2#bid，clarithromycin 500mg 1#bid）for eradication. The eradication result used urea breath test, C13 for following up at least 4 weeks later. We collected gastric juice simultaneously when endoscopy exam. Then we extracted H.pylori DNA and host DNA by managing gastric juice with series process. First of all, confirming the existence of H.pylori by performing PCR of urease A and cag A. Next, checking the resistance of clarithromycin by PCR-RFLP if point mutation of 23srRNA. If positive finding with resistance of clarithromycin, we sent samples for DNA sequencing to exam the point mutation of GyrA gene relating to resistance of levofloxacin. In addition, analyzing polymorphism of CYP2C19 and Interleukin-1Beta 511 gene provided factor that influencing eradication rates. Finally, we analysis these results by SPSS software, version 22th.

Result:

In experimental group, total 62 patients treated by gastric juice analysis result guiding, the eradication rate reached 88.7%(55/62). There were 49 patients without resistance to clarithromycin in experimental group, using traditional 7-day triple therapy achieved 87.8% eradication rate. Rest 13 patients of experimental group with resistance to clarityhromycin, 8 patients with resistance to levofloxacin and 5 patients without resistance to levofloxacin. The eradication rate was 100%(8/8) and 80%(4/5). In control group, all 61 patients treated by traditional 7-day triple therapy, the eradication rate was 75.4%(46/61). Comparing these two groups, the eradication rate was considered statistically significant, P<0.05. We also analyzed the impact of CYP2C19 and IL-1B-511 on eradication rate. The result showed higher eradication rate in CYP2C19 PM type than non-PM type; higher eradication rate in non-HomEM than HomEM type. About IL-1B-511, the result revealed higher eradication rate in T/T type than non-T/T type; non-C/C type than C/C type.
Conclusion:
According to experimental results, using gastric juice analysis can quickly acquire if existence of H. pylori, antibiotic resistance, and polymorphism of CYP2C19 and Interleukin-1Beta 511 gene. Using these results helps clinicians chose correct regimen for first line eradication. These method not only performed convenient and quickly but also less impacted by CYP2C19 polymorphism. In conclusion, it acquires satisfying result in double resistance strain and enhancing first line eradication rate significantly.

並列關鍵字

gastric juice ； helicobacter pylori ； first line

參考文獻

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