ORIGINALE VERBALE DI DELIBERAZIONE DI COMMISSARIO STRAORDINARIO OGGETTO: PATROCINIO E CONCESSIONE GRATUITA PALASPORT ''F.TAGLIALATELA'' PER SVOLGIMENTO VEGLIA DI PREGHIERA A CHIUSURA DELL'ANNO GIUBILARE ANTONIANO (56/2006). IL COMMISSARIO STRAORDINARIO l'anno , addì sedici, del mese di gennaio, nella Casa Comunale di Ischia, assistito dal Segretario Generale AMODIO GIOVANNI. REL
Australian people can buy antibiotics in Australia online here: http://buyantibioticsaustralia.com/ No prescription required and cheap price!
V9n2Rev Biomed 1998; 9:92-96.
Helicobacter pylori: susceptibility
to amoxycillin, erythromycin,
nitrofurantoin and metronidazole
in Costa Rica.
Eugenia M. Quintana-Guzmán1, María L. Arias-Echandi1, Pilar Salas-Chaves1, Henry Davidovich-Rose2,Karl Schosinsky-Neverman1.
1Facultad de Microbiología, Universidad de Costa Rica, 2Servicio de Gastrocopía, Hospital de SanVicente de Paul, Heredia, Costa Rica.
Discussion. These results support the idea of
Objective. To determine the sensibility pattern of
evaluating new treatment therapies in Costa Rican strains of H. pylori isolated from Costa Rican inhabitants in order to eradicate this bacteria.
(Rev Biomed 1998; 9:92-96)
Material and methods. The susceptibility to
antibiotics of 41 strains of Helicobacter pylori
Key words: Helicobacter pylori, antibiotics,
isolated from 34 Costa Rican patients, 20 male and 14 female, was evaluated using the disk diffussiónmethodology. Six different antibiotic discs weretested (amoxycillin (10 µg), erythromycin (5 µg) tetracycline (10 µg), ciprofloxacin (1 µg), Helicobacter pylory: Susceptibilidad de la
nitrofurantoin (50 µg) and metronidazole (5 µg)).
amoxilina, eritromicina, tetraciclina,
Results. Metronidazole showed the greatest rate
ciprofloxacina, nitrofurantoína y metronidazol
of resistance (95.1%), followed by erythromycin en Costa Rica.
(92.6%). Nitrofurantoin and ciprofloxacin Objetivo. Determinar los patrones de sensibilidad
presented the highest rates of sensibility (90.2 and de cepas de Helicobacter pylori aisladas de habi- 92.7% respectively). There is no statistical difference in the percentages of resistance between Material y métodos. Se ev aluó la suceptibilidad
a antibióticos a 41 cepas de Helicobacter pylori Corresponding addres: Dra. María L. Arias-Echandi. Facultad de Microbiología, Universidad de Costa Rica, Ciudad Universitaria "Rodrigo Facio".
Costa Rica, América Central.
Received October 16, 1997; Accepted January 21, 1998.
This paper is also available at http://www.uady.mx/~biomedic/rb98923.html
Vol. 9/No. 2/Abril-Junio, 1998
EM Quintana-Guzmán, ML Arias-Echandi, P Salas-Chaves y col.
aisladas a partir de 34 pacientes costarricenses, 20 ces gastric HCl and makes the mucus present more hombre y 14 mujeres, usasando la metodología de fluid, allowing an increased exposure to the mu- difusión en disco. Se analizaron seis diferentes dis- cosa (4). The effect on the mucosa is increased by cos de antibióticos (amoxilina (10 µg), eritromicina the action of a cytotoxic toxin, which produces a (5 µg), tetraciclina (10 µg), ciprofloxacina (1 µg), vacuolization of the gastric epithelial cells. These nitrofurantoína (50 µg) y metronidazol (5 µg).
characteristics, joined with other environmental Resultados. El metronidazol presentó el mayor
predisposing factors such as stress, smoking, use porcentaje de resistencia (95.1%), seguido por of certain drugs, etc., play a very important role in la eritromicina (92.6%). Los antibióticos que the development of peptic ulcer (4).
presentaron los mayores porcentajes de suscep- tibilidad fueron la nitrofurantoína (90.2%) y la with different antimicrobial agents, in order to ciprofloxacina (92.7%). No hubo diferencia es- determine which one is the most efficient in the tadística en los porcentajes de resistencia a los erradication of this microorganism from the gas- antibióticos entre hombres y mujeres.
tric mucosa (5-7). Although the organism is sen- Discusión. Los resultados apoyan la idea de
sitive to many antibiotics in vitro, the in vivo era- evaluar nuevas terapias de tratamiento en los dication rate is often disappointing based on a pacientes costarricenses para lograr erradicar esta quick appearance of resistant strains and due to bacteria. (Rev Biomed 1998; 9:92-96)
the very acid gastric pH, antibiotics present lo-wer inhibitory concentrations.
Palabras clave: Helicobacter pylori, antibióticos,
therapeutic regimes are applied, two combine theaction of bismuth and metronidazole withtetracycline or amoxycillin the third one uses OBJECTIVE.
omeprazole and amoxicillin. None of these three Helicobacter pylori (H. pylori) is a genus of regimes is completely satisfactory, what's more, microaerophilic, motile, Gram negative curved they imply important side effects and a reduced bacilli, that is widespread in the community and therapeutic effectivity in populations that present usually persists throughout a patients’ life. It is a high resistance to nitromidazoles (8). As a result, considered to be the most important factor in the 5-20% of patients with a potentially curable aetiology of duodenal ulcer and the majority of the disease stay at risk of developing recurrent or benign, non-drug induced gastric ulcers. It has also complicated ulcer disease or progession of gatritis been associated as a risk factor in the development In Costa Rica, the first description of this Due to its wide distribution, association agent was made in 1988 (11,12). Its prevalence with different pathological effects and especially in patients with gastritis is of 70% and in peptic with cancer, in 1994 the National Institute of ulcer near to 90%. The actual treatment offered Health Consensus Development Conference on to Costa Rican patients includes the use of H. pylori in peptic ulcer disease recommended metronidazole and tetracycline or amoxycillin, its eradication in all patients with documented agents associated with side effects and resistance H. pylori presents urease activity, a condi- tion that represents an adaptation for the gastric sensibility pattern of strains of H. pylori isolated enviroment (1). This enzyme has been describred from Costa Rican inhabitants, evaluating the most as an important virulence factor since it neutrali- commonly used antibiotics in order to determine Revista Biomédica
Susceptibilidad de H. pylori a antibióticos.
the effect of these on the potential eradication of zone were considered as resistant mutants. An inhibition zone of < 21 mm for amoxycillin and14 mm for metronidazole was considered asresistant (13).
MATERIAL AND METHODS.
For 41 H. pylori strains, the susceptibility to Forty one clinical isolates coming from 34 patients (20 male and 14 female) that assisted to ciprofloxacin, nitrofurantoin and metronidazole the Gastroscopy Service, Hospital San Vicente de was determined by disc diffusion test. The overall Paul, Heredia, Costa Rica were studied for their resistance to these antibiotics is presented in table sensibility pattern at the Microbiology Faculty, 1. The antibiotic that exhibited the greatest rate of University of Costa Rica. The isolates were resistance was metronidazole (95.1%) followed by identified using Gram stain, motility, oxidase, nitrofurantoin presented the highest rates of The strains were stored at -70oC in tryptic sensibility (7.4 and 9.8%, respectively).
soy broth (TSB) containing 15% (v/v) glycerol for For the different antibiotics tested, there is less than a month before the antibiotic analysis.
no statistical difference in the percentage of Inoculum.
resistance to all the six antibiotics tested.
The susceptibility to antibiotics was tes- ted using the disk diffusion assay, according to the methodology described by López Brea Resistance of H. pylori to amoxycillin,
& Alarcón (13). Freezed vials containing the ciprofloxacin, erythromycin, metronidazole,
different strains were inoculated on blood agar nitrofurantoin and tetracycline in 41 different
and incubated microaerophylically (Anaerobic isolates from Costarrican patients.
System BBL®) for five days. Colonies weresuspended in 1 mL tryptic soy broth pH 7.2 to a density of 0.5 McFarland (approximately106 CFU/mL). 0.5 mL of this inoculum was flooded to a non selective blood agar plate and allowed to dry for 5-10 min. Six different dis- c s w e r e t e s t e d ( a m o x y c i l l i n ( 1 0 µ g ) , erythromycin (5 µg), tetracycline (10 µg), ci- profloxacin (1 µg), nitrofurantoin (50 µg) and metronidazole (5 µg) (Piqaux®). They wereincubated under microaerophilic conditions at 35oC for 72 h.
based on the size fo the inhibition zone defined Numerous eradication regimes to cure H. for tetracycline, erythromycin, ciprofloxacin pylori infections have been published. New the- and nitrofurantoin, large zones of inhibition rapies keep being lauched, some with adequate around the disc were defined as sensible and effects and others with variable eradication re- growth to the edge of the disc meant resistance, any small colonies growing within the inhibition Because the eradication of H. pylori has not Vol. 9/No. 2/Abril-Junio, 1998
EM Quintana-Guzmán, ML Arias-Echandi, P Salas-Chaves y col.
always been successful, reasons for such failures 19.6% in the present study. Literature indicates that have been suggested to be due either to side effects this antibiotic also exhibits very low eradication presented by the patient with the eventual abandonment of the treatment, or to the resistance The resistance to amoxycillin by H. pylori has of the bacteria to the antibiotics used.
not been evaluated by big models, but there is an H. pylori is relatively sensible to a wide variety important number of people that present allergy to of antibiotics in vitro, but in vivo is quite difficult to eradicate (15) from the gastric mucosa, due to Nitrofurantoin is a drug of small use around desnaturalization of the molecules by acid pH (13), the world except for Latin America, it is expected impermeability to these or even their evacuation of to present an eradication rate for Helicobacter pylori around 70%. In this work, nitrofurantoin presented The resistance to different antibiotics vary a very high sensibility, being of 90.2%.
considerably around the world. Some of this The H. pylori strains analyzed presented an variations may be due to different techniques defining important susceptibility to ciprofloxacin (92.7%), an in vitro resistance (16). Nevertheless, the increased universal behavior (20), since this antibiotic presents use of certain antibiotics for different purposes a resistance rate ranging from 5 to 15%, which could created a selective pressure for the development of be explained based in a lower comsumption of this drug resistance. Often, many of these users would be asymptomatically infected with H. pylori which The monotherapy for the eradication of H. pylori is not used anymore. New therapies include The use of antibiotics in our country has been the use of antiacids or bismuth with metronidazole indiscriminated, this explains the very high resistant and amoxycillin or tetracycline, even though the rates found in this work to common antibiotics such patient may present resistance to them. What's more, as metronidazole (95.1%) and erythromycin numerous studies show that when triple therapy is (92.6%). Clinical studies have shown that metroni- given to patients harboring resistant strains, dazole resistance has developed after ineffective eradication can still be obtained in a considerable treatments, either in gynecological infections or for number (22) especially if theraphy of longer duration diarrheal illnesses (17). The world-wide prevalence of metronidazole resistance, which develops rather There was no statistical difference between quickly (18) ranges from 10 to 90%, being Europe males and females in the resistance to the different and Australia the populations that present the lo- antibiotics evaluated as has been found in other west resistance rates and Central Africa the one with studies (17), this can be explained by the highest resistance rate (70-90%) (17). Our country indiscriminate and abusive use of antibiotics that has has to be included in this last group. Nevertheless, been going on in the country for years.
there is no scientific basis to believe that strains of This study shows an important resistance to H. pylori resistant to metronidazole are more likely metronidazole, erythomycine and tetracycline from than sensitive strains to cause ulcer disease, dyspep- the population, so considerable effort has to be directed towards the introduction of new therapies Treatment of H. pylori with erythromycin has that include the use of antibiotics such as shown very poor results, the susceptibility rate nitrofurantoin and ciprofloxacin in order to eradicate described is lower than 10%, similar to the results this bacteria. The ideal treatment should be simple, obtained (7.4%). This may be due to a reduction in effective, economic, free of side effects and with high the efficiency of the molecule at an acidic pH (19).
rates of eradication. Also, further in vivo trials shall Tetracyclines presented an eradication rate of be done with Costa Rican inhabitants in order to Revista Biomédica
Susceptibilidad de H. pylori a antibióticos.
find the most simple and effective forms of therapy 11.- Rivera P, Hernández F, Sigarán M, Aguilar-Ortíz M.
Primer informe sobre el aislamiento de Campylobacterpylori en gastritis crónica atrófica en Costa Rica. Rev CostCienc Med 1988; 9:43-46.
12.- Hernández F, Rivera P, Sigarán M. The first cases of We wish to thank Laura Villalobos for her Helicobacter pylori reported from Costa Rica. Rev Biol Trop 13.- López Brea M, Alarcón T. Sensibilidad antimicrobiana REFERENCIAS.
en la infección por Helicobacter pylori. En: López Brea 1.- Marshall BJ. Helicobacter pylori. Am J Gastroenterol M. Helicobacter pylori Microbiología, Clínica y Tratamien- to. 2 ed.; Madrid: Mosby/Doyma Libros; 1995. p. 32-53.
2.- Axon ATR. Helicobacter pylori In: Pounder RE, ed.
14.- Axon ATR Campylobacter pylori-therapy review.
Recent Advantages in Gastroenterology. Edinburgh: Scand J Gastroenterol 1989; 29:35-38.
Churchill Livingsstone; 1992. p. 27-48.
15.- McNulty CA, Dent J, Wise R. Susceptibility of clinical 3.- NIH Consensus Conference. Helicobacter pylori in isolates of Campylobacter pyloridis to 11 antimicrobial peptic ulcer disease. JAMA 1994; 272:65-69.
agents. Antimicro Agent Chemother 1985; 28:837-38.
4.- Malfertheiner P, Deltenre M. Helicobacter pylori 16.- Vander Huylst RWM, Weel JFL, Vander Ende A, Ten eradication: the rational treatment for peptic ulcer disease - FJW, Dankert J, Tytgat GNJ. Therapeutic options after failed Chaimen’s discussion. Scand J Gastroenterol 1994:59-60.
Helicobacter pylori eradication. Amer J Gastroenterol 1996;91:2333-37.
5.- Bernard PH, Cayla R, Megraud F, de Mascarel A,Quinton A. Controlled study of omeprazole-amocycillin- 17.- Walt RP. Metronidazole resistant Helicobacter pylori tinidazole vs ranitidine-amocycillin-tinidazole in of questional clinical importance. Lancet 1996; 348:489- Helicobacter pylori associated duodenal ulcer.
18.- Hilpi R, Seppala K, Renkonar O, Vainio V, Kosunen 6.- McCarthy CJ, Collins R, Beattie S, O’Morain C. Long T. Role of metronidazole resistance in therapy of term study of omeprazole triple theraphy in Helicobacter Helicobacter pylori infections. Antimicro. Agents and pylori associated duodenal ulcer. Gastroenterology 1992; 19.- Megraud F y Lamouliatte H. Tratamiento de la infec- 7.- Hentschel E, Brandstter G, Dragosics B. Effect of ción por Helicobacter pylori. En: López Brea M.
ranitidine and amoxycillin plus metronidazole in the Helicobacter pylori Microbiología, Clínica y Tratamiento.
eradication of Helicobacter pylori and the recurrence of 2 ed.; Madrid: Mosby/Doyma Libros; 1995. p. 241-58.
duodenal ulcer disease. N Eng J Med 1993; 328:308-12.
20.- Zeiler HJ, Grohe K. The in vitro and in vivo activity of 8.- Axon ATR. The role of omeprazole and antibiotic ciprofloxacin. Eur J Clin Microb 1984; 3:339-43.
combinations in the eradication of Helicobacter pylori - anupdate. Scand J Gastroenterol 1994; 205:31-37.
21.- Glupczynski Y. Culture of Helicobacter pylori fromgastric biopsies and antimicrobial susceptibility testing. In: 9.- McColl K. The role of Helicobacter pylori in the Lee A, Megraud F. Helicobacter pylori techniques for management of acute bleeding peptic ulcer. Eur J clinical diagnosis and basic research. 2 ed. London: W.B.
Gastroenterol Hepatol 1995; 7:753-55.
10.- Vander Hulst RWM, Tytgat GNJ. Helicobacter pylori 22.- Tytgat GNJ, Axon ATR, Dixon MF, Graham DY, Lee and peptic ulcer disease. Scand J Gastroenterol 1996; 31:10- A, Marshall BJ. Helicobacter pylori causal agent in peptic ulcer disease? Working Party Report of the World Congress in Gastroenterology. Sydney: Blackwell; 1995. p. 36-45.
Vol. 9/No. 2/Abril-Junio, 1998
FLUTTER® Mucus Clearance Device Instructions for Use PRODUCT DESCRIPTION The FLUTTER® mucus clearance device is shaped like a pipe with a hardened plastic mouthpiece at one end, a plastic protective, perforated cover at the other end, and a high-density stainless steel ball resting in a plastic circular cone on the inside (Figures 1 and 2). INDICATIONS The FLUTTER® provides posi