H pylori #tweetorial for resistant H pylori
#AGA released CPU in 4/21 revisiting topic of resistance/treatment failures, not a guideline, but the expert opinion @BradSpellberg loves! (1/x)
gastrojournal.org/article/S0016-…
@ABsteward @RushCCH_ID #MedEd #medtwitter #idtwitter
As GN bacteria go, it's an interesting bug:
Highly motile, curved, GNR, #Urease-positive, catalase-positive, oxidase-positive
Related to Campylobacter, for family fun
Nice crossover with our #Gastroenterology colleagues, eh #IDtwitter and @IDSAInfo
(2/x)
GN, and as such should be sensitive to most #antibiotics that target GN with pretty good susceptibilities over time for:
#amoxicillin #tetracycline #aminoglycoside #nitroimidazole #macrolide
(3/x)
Historically, we've grown up as a species together, and it seems that during #evolution, we've both benefited.
Data suggest reduction in #asthma of childhood, and other atopic syndromes like #eczema (gotta be some #Pediatrics #Pulmonary folks interested, right?)
(4/x)
Though thriving in acidic environments, it's not the cause of #GERD, but instead of chronic #gastritis, and subsequently #ulcers (duodenal > gastric, thanks #NSAIDs) given increased gastrin production (5/x)
They also have 2 Lewis #antigens that perform molecular mimicry thereby promoting H pylori persistence, as T-regulatory cells downregulate inflammatory responses, hence why over time you have less acute symptoms, but risk of #cancer etc
Look for CagA + for CA
(6/x)
Also affects our #leptin #ghrelin pathways, so may drive metabolic presentations of satiety and weight gain, with eradication leading to more weight gain as less satiety (7/x)
Often missed with acute infection:
n/v/epigastric pain x3-14d w/ intense #gastritis weeks later, & up to one year of hypochlorhydria (#gastrin overdrive leading to burnout of production)
(please #Gastroenterology chime in whenever, or some ID/GI guru if differing thoughts!) (8/x)
(9/x) Image
So, as #infectiousdiseases when do we get called? Doesn't #Gastroenterology handle this? Or #primarycare ? First let's look at indications, and initial management (10/x)
Indications: #PUD #MALToma (eradication causes tumor regression) high risk gastric CA patients, s/p early resection of gastric CA
Rarely and as diagnosis of exclusion: ITP, B12 def, IDA
Only small improvement benefit in non-ulcerative dyspepsia, so not recommended
(11/x)
Principles of treatment
1.Monotherapy drives down prevalence, but not useful for eradication
2.Low pH makes #antibiotics ineffectual
3.Lots of acquired resistance (FLQ, macro, Flagyl)
4.Check #eradication 1m after tx with bx, UBT, HpSA, or 6m after with serological titers
(12/x)
First, gotta have #diagnosis!
Invasive vs Non-Invasive
#EGD/#biopsy with stains and cultures and possibly PCR
or
Serum #serology, #urease breath test, fecal #antigen test
(13/x)
Serology #IgG based, as #IgM dropped off after ~21 days
Not vetted in peds
Can check after treatment 6m for low titer to no titer marker
Rapid #hpyloritestkit have low SENS/SPEC
Use in appropriate clinical settings/picture
(14/x)
#urease breath test UBT
take in some carbon 13 and 14 urea, then breathe out an hour later and find the CO2 with the 13 and 14
NEEDS TO BE OFF #protonpumpinhibitors for minimum 14 days! Otherwise false negative
Also, prior abx use for any condition may give false (-)
(15/x)
Stool #Antigen Test (HpSA)
monoclonal Ab in test bind HpAg
Off PPIs again for 14 days to avoid false results!
Some patient avoidance of test given need to obtain sample themselves
(16/x)
First line treatment!
Triple
- clarithro, amox, PPI
or
Quadruple therapy
- Bismuth, metro, tetra, PPI
- Non-Bismuth = amox, PPI, metro, clarithro
(17/x) Image
#Bismuth is #bactericidal here, and interrupts mucosal adherence
#PPIs inhibit #urease activity and improve #antibiotics #efficacy by raising #pH!
(18/x)
Initial management has 10-20% failure rate!
#AntimicrobialResistance
#Fluoroquinolone resistance occurs after first exposure
#metronidazole has known 20-40% resistance rate esp in F w/ prior exposure
#clarithromycin resistance after exposure
Consider colonized, so⬆️exp
(19/x)
Tenets for Failure:
1.Don't reuse clarithromycin in second or third line therapy!
2. No amoxicillin resistance, increase dosing/timing to have high troughs, 2-3g q6-q8h (PCN allergy testing PRN)
3. 14 days >10 days @BradSpellberg #longerisbetter
4.PPI adherence paramount!
(20/x)
Studies show #empiric treatment #noninferior to in vitro resistance testing
May reuse FLQ, and metro; avoid clarithro!
AGA CPU 2021 update below!
(21/x) Image
So, that's the upfront! First true #tweetorial attempt...
Lemme know if there are questions!
#MedEd #medtwitter #IDtwitter #hpylori #Gastroenterology #pepticulcerdisease #AntimicrobialResistance
@ABsteward @BradSpellberg @RushCCH_ID
(22)
@mohammad from a GI perspective, leave your thoughts throughout!
@emilytemplewood any cases in your FP residency you’ve come across?
@briden_danielle in the GMO world?

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More from @JamesWilsonDO1

May 22
Empiric dual antipseudomonal coverage:
When do you use it, and why is it only in neutropenic septic shock?
#neutropenia #sepsis #pseudomonas #antibiotics #antimicrobialstewardship #IDTwitter @ABsteward @ABStewardess @IDstewardship @IDdocAdi @DrToddLee @BradSpellberg @IdVilchez
🧵
@IDiots_pod & @DrToddLee
#aminoglycoside on top of beta lactam backbone FTW..?
2/2 Post antibiotic effect while cx cooking from 1 dose?
@InYourFAECIUM @IDstewardship #TwitteRx @ABsteward
(FQ mono tx is NEVER the answer in shock, & in combo tx the BL is doing the heavy lifting)
Amikacin “better” for PsAr, but tobra better penetration in the lungs. What’s the go to? For me? Amikacin in worsening GI shock, tobra for pulm. #aminoglycoside
Read 11 tweets
May 2
#sepsis
Is sparing even one more day of multi #vasopressor support worthwhile in #septicshock? #sscguidelines @SCCM #CriticalCare #idcrit #pulmtwitter #MedTwitter #FOAMcc #TwitteRx @CritCareIDN @IM_Crit_ @PulmCrit @IDCritMD @raj_karnatak @MBrigmon @NephRodby @medrants
1/14 🧵
How do you “get there?”
@SCCM @SurvivingSepsis #sscguidelines & available lit suggests #albumin may allow ~1 more pressor-free day (poss #ICU LOS as well, debated)
2/14 🧵
New #sccm #cortiocsteroids in #sepsis guidelines also suggest earlier initiation of stress dose steroids provides ~1 more pressor-free days w improved ICU LOS
3/14 🧵
Read 14 tweets
Nov 25, 2023
Where did the #sepsis 30mL/kg IVF rec come from?
After Rivers’ EGDT in 2001 until 2015, the literature was combed to find how much reasonable physicians gave to septic patients and their outcomes. That #? ~2-3L. Which is ABOUT 30mL/kg for the average sized adult.
Thought 🧵 1/6
I say “reasonable physicians” as the SSC guidelines admit this was decided upon from the average amount given in the pre randomization of PROCESS, ARISE, PROMISE trials. That amount being 2-3L.
#MedTwitter #pulmtwitter #FOAMed #MedEd #critcare #emergencymedicine
2/6
So. Should we NOT give it? Should we give it based on IDEAL or ACTUAL body weight (obese vs overly muscular have diff H2O reserves)? Should we give it only to those patients WITHOUT HFrEF/HFpEF or CKD4-5-ESRD or cirrhosis?

Should we *gasp* INDIVIDUALIZE it..?!
3/6
Read 13 tweets

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