Alternative eradication regimens for helicobacter pylori infection in indonesian regions with high metronidazole and levofloxacin resistance

Muhammad Miftahussurur, Langgeng Agung Waskito, Ari Fahrial Syam, Iswan Abbas Nusi, Gontar Siregar, Marselino Richardo, Achmad Fuad Bakry, Yudith Annisa Ayu Rezkitha, I. Dewa Nyoman Wibawa, Yoshio Yamaoka

Research output: Contribution to journalArticlepeer-review

28 Citations (Scopus)


Background: The prevalence of Helicobacter pylori resistance to metronidazole and clarithromycin is high in Indonesia. Moreover, the increasing levofloxacin resistance rates in the absence of bismuth treatment in Indonesia has led to the use of other antibiotics as alternative regimens. Methods: We determined the minimum inhibitory concentrations (MICs) of five alternative antibiotics for H. pylori (rifaximin, rifabutin, furazolidone, garenoxacin, and sitafloxacin) using the agar dilution method and assessed mutations associated with antibiotic resistance using next-generation sequencing. Result: Analysis of 106 strains isolated from 1039 adult dyspeptic patients revealed that none of the strains were furazolidone-resistant. All strains were also sensitive to rifabutin and sitafloxacin. In contrast, the rates of resistance to rifaximin and garenoxacin were high (38.9% and 6.7%, respectively). The strains isolated from patients on Java Island had the highest resistance rates to garenoxacin and rifaximin. In addition, the resistance was distributed evenly among the ethnic groups, ranging between 25.0% and 69.2%. Except for rifaximin, for which the resistance rate was 38.9%, the other four antibiotics could be successfully employed to eradicate levofloxacin-and metronidazole-resistant H. pylori infections in vitro. Interestingly, garenoxacin-sensitive strains were found in regions with high clarithromycin resistance rates such as Bali and Papua Islands. In contrast, rifaximin might not be considered as an alternative antibiotic in regions with high clarithromycin resistance. There was an inconsistent association between gyrA and gyrB mutations and garenoxacin resistance. We confirmed that the I837V (replacement of isoleucine at position 837 with valine), A2414T/V, Q2079K and K2068R were the predominant rpoB point mutations. There was an association between vacA genotypes of H. pylori and rifaximin resistance (P = 0.048). Conclusion: furazolidone-, rifabutin-, and sitafloxacin-based therapies might be considered as alternative regimens to eradicate H. pylori in Indonesia, including regions with high metronidazole and clarithromycin resistance rates. Moreover, sitafloxacin but not garenoxacin should be considered for eradication of levofloxacin-resistant strains.

Original languageEnglish
Pages (from-to)345-358
Number of pages14
JournalInfection and Drug Resistance
Publication statusPublished - 2019


  • Antibiotics
  • Drug resistance
  • Helicobacter pylori
  • Indonesia


Dive into the research topics of 'Alternative eradication regimens for helicobacter pylori infection in indonesian regions with high metronidazole and levofloxacin resistance'. Together they form a unique fingerprint.

Cite this