胃腺癌是全球癌癥死亡的第二大原因,。盡管胃癌發(fā)病率在某些地區(qū)正在下降，但因?yàn)樵谥T如拉丁美洲和東亞等高發(fā)病率地區(qū)人口的增長和老化,，其死亡人數(shù)預(yù)計會在未來的幾十年中增加。幽門螺旋桿菌感染了世界上超過一半的成年人,，而這種細(xì)菌的慢性感染是胃癌的主要風(fēng)險因素,，據(jù)估計它占了全球所有病例的三分之二。
據(jù)發(fā)表在2月13日出版的《美國醫(yī)學(xué)會雜志》上的一則研究披露,，在一項(xiàng)對拉丁美洲7個不同社區(qū)人群的根除幽門螺旋桿菌（一種可導(dǎo)致胃癌的風(fēng)險因子）治療干預(yù)結(jié)果的分析中,，研究人員發(fā)現(xiàn)，在根除幽門螺旋桿菌的治療干預(yù)中,，地理位置,、人口因素、對最初治療的堅持以及感染的復(fù)發(fā)可能與抗菌素療法的選擇同樣重要,。
田納西州納什維爾市范德比爾特醫(yī)學(xué)中心的Douglas R. Morgan, M.D., M.P.H.及其同事對幽門螺旋桿菌的復(fù)發(fā)風(fēng)險進(jìn)行了估計,， 并評估了在用3種療法之一進(jìn)行治療1年之后與成功根除該菌有關(guān)的因素。這項(xiàng)研究包括了1463名來自7個拉美社區(qū)的年齡在21-65歲的參與者,，他們接受了幽門螺旋桿菌的治療并在2009年9月至2011年7月間接受了觀察。研究通過使用來自一個家庭人口普查（哥倫比亞,、哥斯達(dá)黎加,、尼加拉瓜）、一個大型公共臨床診所登記（智利）,，或家庭招募（洪都拉斯及墨西哥的兩個地方）的信息對可能的參與者進(jìn)行了遴選,。參與者被隨機(jī)分配至3個治療組中的1組：為期14天的蘭索拉唑、阿莫西林及克拉霉素（三聯(lián)療法）,；為期5天的蘭索拉唑及阿莫西林及接下來為期5天的蘭索拉唑,、克拉霉素及甲硝唑（順序療法）；或?yàn)槠?天的蘭索拉唑,、阿莫西林,、克拉霉素及甲硝唑（伴同療法）。
在最初治療后,，1133名尿素呼氣試驗(yàn)（UBT;這是一種用于確認(rèn)幽門螺旋桿菌存在的診斷程序）呈陰性的參與者中,，有1091人具有1年時的UBT 結(jié)果，其中125人變成UBT陽性,，其復(fù)發(fā)風(fēng)險為11.5%,。研究人員發(fā)現(xiàn)，1年時的復(fù)發(fā)率與研究地點(diǎn),、家庭中孩子的數(shù)目及不堅持治療有著明顯的關(guān)系,，但與治療方式的指派沒有關(guān)系,。
在對基于具有肯定的1年時UBT結(jié)果的1340位參與者治療效果的初步分析中，所估計的在1年時根除的成功率對三聯(lián)療法為80.4%,、對順序療法為79.8%,、對伴同療法為77.8%?？傮w有效率為79.3%,。
文章的作者寫道：“在一項(xiàng)忽略再治療效果的單一療程分析中，1年時UBT陰性結(jié)果百分比為72.4%,，且它與研究地點(diǎn),、對最初療法的堅持、男性性別及年齡有著明顯的關(guān)系,。所有1463名入選參與者在1年時的治療有效率——如果將所有缺失的UBT結(jié)果視作陽性——為72.7%,。” (生 物 谷Bioon.com)
doi:10.1001/jama.2013.311
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Risk of Recurrent Helicobacter pylori Infection 1 Year After Initial Eradication Therapy in 7 Latin American Communities
Douglas R. Morgan, MD, MPH; Javier Torres, PhD; Rachael Sexton, MS; Rolando Herrero, MD, PhD; Eduardo Salazar-Martínez, MD; E. Robert Greenberg, MD; Luis Eduardo Bravo, MD; Ricardo L. Dominguez, MD; Catterina Ferreccio, MD, MPH; Eduardo C. Lazcano-Ponce, MD, PhD; Maria Mercedes Meza-Montenegro, PhD; Edgar M. Pe?a, MD, MPH; Rodolfo Pe?a, MD, DrPH; Pelayo Correa, MD; María Elena Martínez, PhD; William D. Chey, MD; Manuel Valdivieso, MD; Garnet L. Anderson, PhD; Gary E. Goodman, MD, MS; John J. Crowley, PhD; Laurence H. Baker, DO
Importance The long-term effectiveness of Helicobacter pylori eradication programs for preventing gastric cancer will depend on recurrence risk and individual and community factors.
Objective To estimate risk of H pylori recurrence and assess factors associated with successful eradication 1 year after treatment.
Design, Setting, and Participants Cohort analysis of 1463 randomized trial participants aged 21 to 65 years from 7 Latin American communities, who were treated for H pylori and observed between September 2009 and July 2011.
Interventions Randomization to 1 of 3 treatment groups: 14-day lansoprazole, amoxicillin, and clarithromycin (triple therapy); 5-day lansoprazole and amoxicillin followed by 5-day lansoprazole, clarithromycin, and metronidazole (sequential); or 5-day lansoprazole, amoxicillin, clarithromycin, and metronidazole (concomitant). Participants with a positive (13) C-urea breath test (UBT) 6 to 8 weeks posttreatment were offered voluntary re-treatment with 14-day bismuth-based quadruple therapy.
Measurements Recurrent infection after a negative posttreatment UBT and factors associated with successful eradication at 1-year follow-up.
Results Among participants with UBT-negative results who had a 1-year follow-up UBT (n=1091), 125 tested UBT positive, a recurrence risk of 11.5% (95% CI, 9.6%-13.5%). Recurrence was significantly associated with study site (P = .03), nonadherence to initial therapy (adjusted odds ratio [AOR], 2.94; 95% CI, 1.31-6.13; P = .01), and children in the household (AOR, 1.17; 95% CI, 1.01-1.35 per child; P = .03). Of the 281 with positive posttreatment UBT results, 138 completed re-treatment, of whom 93 tested UBT negative at 1 year. Among the 1340 who had a 1-year UBT, 80.4% (95% CI, 76.4%-83.9%), 79.8% (95% CI, 75.8%-83.5%), and 77.8% (95% CI, 73.6%-81.6%) had UBT-negative results in the triple, sequential, and concomitant groups, respectively (P = .61), with 79.3% overall effectiveness (95% CI, 77.1%-81.5%). In a single-treatment course analysis that ignored the effects of re-treatment, the percentage of UBT-negative results at 1 year was 72.4% (95% CI, 69.9%-74.8%) and was significantly associated with study site (P < .001), adherence to initial therapy (AOR, 0.26; 95% CI, 0.15-0.42; P < .001), male sex (AOR, 1.63; 95% CI, 1.25-2.13; P < .001), and age (AOR, 1.14; 95% CI, 1.02-1.27 per decade; P = .02). One-year effectiveness among all 1463 enrolled participants, considering all missing UBT results as positive, was 72.7% (95% CI, 70.3%-74.9%).
Conclusions and Relevance One year after treatment for H pylori infection, recurrence occurred in 11.5% of participants who had negative posttreatment UBT results. Recurrence determinants (ie, nonadherence and demographics) may be as important as specific antibiotic regimen in determining the long-term success of H pylori eradication interventions. Study findings are relevant to the feasibility of programs for the primary prevention of gastric cancer in high-incidence regions of Latin America.
