Page 1, 2
Helicobacter Pylori and Antibiofilm Enzymes
H. pylori resides within biofilm overlying and within gastric mucus.49 Biofilm microorganisms are 10 to over 1000 times more resistant to antibiotics than their free-living kindred.45 A biofilm matrix is primarily composed of exopolysacchrides. Cellulose, a polymer of b-(1®6) linked D-glucose sugars associated with plants, is a particularly ubiquitous component of biofilms made by gram-negative microorganisms.62 A nutraceutical enzyme formulation has been developed that combines cellulase with other carbohydrases and proteases. This formulation has broad antibiofilm activities against an array of pathogenic biofilms including H. pylori.63 It has been shown in the laboratory to have significant synergism against H. pylori with amoxicillin, tetracycline, and clarithromycin, but not with metronidazole. The observed synergistic effects suggest the enzyme formulation may be combined with standard triple therapy with clarithromycin and amoxicillin to accomplish more effective eradication of gastric H. pylori populations.
Helicobacter Pylori and Lactoferrin
Lactoferrin, a copious glycoprotein constituent of human external secretions, binds iron.64 Lactoferrin has been shown to have antibiofilm properties.65 It also has direct antimicrobial activities against H. pylori.66 A meta-analysis of nine randomized trials comparing lactoferrin supplementation to placebo or no treatment during anti-H. pylori therapies found that lactoferrin significantly increased eradication rates to 87% compared with 74% as well as reducing side effects.67 The addition of lactoferrin to standard as well as adjunctive complementary therapies for H. pylori has great potential to improve outcomes in patients requiring treatment for H. pylori colonization.
Helicobacter Pylori and N-Acetyl-L-Cysteine
N-Acetyl-L-cysteine, the N-acetyl derivative of L-cysteine, is the rate-limiting precursor for glutathione synthesis. Oral N-acetyl-L-cysteine has been used to disrupt H. pylori biofilm and mitigate H. pylori antibiotic resistance. In a small study involving 40 subjects who had failed at least four prior courses of standard therapies, N-acetyl-L-cysteine in addition to a culture-guided antibiotic program was associated with a cure rate of 65% versus a rate of 20% without N-acetyl-L-cysteine.68 The addition of N-acetyl-L-cysteine has significant potential in the treatment of H. pylori, particularly in patients who have failed prior courses of therapy.
Helicobacter Pylori and Quercetin
Quercetin is a potent polyphenolic bioflavonoid water-soluble antioxidant found in many foods including kale, watercress, onions, apples, green tea, and black tea.69 Quercetin has a variety of activities including anti-allergic, anti-inflammatory properties and activation of cellular pathways that lead to the prevention of many pathological conditions such as cancer and cardiovascular and neurodegenerative disease.70 Quercetin has significant in vitroanti-H. pylori effects that are pH independent.71 In an animal study, quercetin reduced H. pylori gastric mucosa infection and decreased inflammatory response and lipid peroxidation.72 This suggests that quercetin may have a useful role in moderating excessive inflammatory responses to H. pylori colonization and in increasing treatment success rates.
H. pylori has been a human gastric commensal microbe for the entire history of the species. It is clearly associated with significant disease, but only a minority of colonized people ever develop disease. H. pylori appears to confer health benefit, and declining colonization rates are associated with increases in esophageal diseases and allergies. The traditional "test and treat" strategy may be excessive, and more focused treatment indications are being preferred. Standard antimicrobial regimens have low and declining success rates. Adjunctive, complementary interventions such as probiotics, antibiofilm enzymes, lactoferrin, N-acetyl-L-cysteine, and quercetin offer the opportunities to improve H. pylori treatment success rates and reduce side effects.
Page 1, 2
1. Dorer MS, Talarico S, Salama NR. Helicobacter pylori's unconventional role in health and disease. PLoS Pathog. 2009;5:e1000544.
2. Bizzozero G. Ueber die schlauchförmigen Drüsen des Magendarmkanalsund die Beziehungen ihres Epithels zu dem Oberfächenepithel der Schleimhaut. Dritte mitteilung. Archiv Mikroskopische Anat. 1893;43:82–152.
3. Savage DC. Microbial ecology of the gastrointestinal tract. Annu Rev Microbiol 1977;31:107–133.
4. Adamsson I, Nord CE, Lundquist P, Sjostedt S, Edlund C. Comparative effects of omeprazole, amoxycillin plus metronidazole versus omeprazole, clarithromycin plus metronidazole on the oral, gastric and intestinal microflora in Helicobacter pylori-infected patients. J Antimicrob Chemother. 1999;44:629–460.
5. Warren JR, Marshall BJ. Unidentified curved bacilli on gastric epithelium in active chronic gastritis. Lancet. 1983;1:1273–1275.
6. Blaser MJ. Helicobacter pylori and the pathogenesis of gastroduodenal inflammation. J Infect Dis. 1990;161:626–633.
7. Parsonnet J, Friedman GD, Vandersteen DP, et al. Helicobacter pylori infection and the risk of gastric carcinoma. N Engl J Med. 1991;325:1127–1131.
8. Wotherspoon AC, Ortiz-Hidalgo C, Falzon MR, Isaacson PG. Helicobacter pylori-associated gastritis and primary B-cell gastric lymphoma. Lancet. 1991;338:1175–1176.
9. Bik EM, Eckburg PB, Gill SR, et al. Molecular analysis of the bacterial microbiota in the human stomach. J Med Microbiol. 2009;58(Pt 4):509–516.
10. Yamaoka Y. Helicobacter pylori typing as a tool for tracking human migration. Clin Microbiol Infect. 2009;15:829–834.
11. Correa P, Piazuelo MB. Evolutionary history of the Helicobacter pylori genome: implications for gastric carcinogenesis. Gut Liver. 2012;6:21–28.
12. Kusters JG, van Vliet AH, Kuipers EJ. Pathogenesis of Helicobacter pylori infection. Clin Microbiol Rev J. 2006;19:449–490.
13. Taniguchi Y, Kimura K, Satoh K, et al. Helicobacter pylori detected deep in gastric glands: an ultrastructural quantitative study. J Clin Gastroenterol. 1995;21 Suppl 1:S169–S173.
14. Sachs G, Wen Li, Scott DR. Gastric infection by Helicobacter pylori. Curr Gastroenterol Rep. 2009;11:455–461.
15. Petersen AM, Krogfelt KA. Helicobacter pylori: an invading microorganism? A review. FEMS Immunol Med Microbiol. 2003;36:117–126.
16. Blaser MJ. Theodore E. Woodward Award: Global warming and the human stomach: microecology follows macroecology. Trans Am Clin Climatol Assoc. 2005;116:65–75.
17. Glickman JN, Antonioli DA. Gastritis. Gastrointest Endosc Clin N Am. 2001;11:717–740, vii.
18. Corso G, Seruca R, Roviello F. Gastric cancer carcinogenesis and tumor progression. Ann Ital Chir. 2012;83:172–176.
19. Ernst PB, Gold BD. The disease spectrum of Helicobacter pylori: the immunopathogenesis of gastroduodenal ulcer and gastric cancer. Annu Rev Microbiol. 2000;54:615–640.
20. Hunt RH, Sumanac K, Huang JQ. Review article: should we kill or should we save Helicobacter pylori? Aliment Pharmacol Ther. 2001;15 Suppl 1:51–59.
21. Ahmed N, Tenguria S, Nandanwar N. Helicobacter pylori – a seasoned pathogen by any other name. Gut Pathog. 2009;1:24.
22. El Serag HB, Sonnenberg A. Opposing time trends of peptic ulcer and reflux disease. Gut. 1998;43:327–333.
23. Brown LM, Devesa SS, Chow WH. Incidence of adenocarcinoma of the esophagus among white Americans by sex, stage, and age. J Natl Cancer Inst. 2008;100:1184–1187.
24. Yamaji Y, Mitsushima T, Ikuma H, et al. Inverse background of Helicobacter pylori antibody and pepsinogen in reflux oesophagitis compared with gastric cancer: analysis of 5732 Japanese subjects. Gut. 2001;49:335–340.
25. Ye W, Held M, Lagergren J, et al. Helicobacter pylori infection and gastric atrophy: risk of adenocarcinoma and squamous-cell carcinoma of the esophagus and adenocarcinoma of the gastric cardia. J Natl Cancer Inst. 2004;96:388–396.
26. De Martel C, Llosa AE, Farr SM, et al. Helicobacter pylori infection and the risk of development of esophageal adenocarcinoma. J Infect Dis. 2005;191:761–767.
27. Islami F, Kamangar F. Helicobacter pylori and esophageal cancer risk: a meta-analysis. Cancer Prev Res (Phila). 2008;1:329–338.
28. Winberg H, Lindblad M, Lagergren J, Dahlstrand H. Risk factors and chemoprevention in Barrett's esophagus-an update. Scand J Gastroenterol. 2012;47:397–406.
29. Zhou X, Wu J, Zhang G. Association between Helicobacter pylori and asthma: a meta-analysis. Eur J Gastroenterol Hepatol. Epub 2012 Dec 13.
30. Hasni SA. Role of Helicobacter pylori infection in autoimmune diseases. Curr Opin Rheumatol. 2012;24:429–434.
31. Ram M, Barzilai O, Shapira Y, et al. Helicobacter pylori serology in autoimmune diseases – fact or fiction? Clin Chem Lab Med. 2012;0:1–8.
32. Harris PR, Wright SW, Serrano C, et al. Helicobacter pylori gastritis in children is associated with a regulatory T-cell response. Gastroenterology. 2008;134:491–9.
33. Freire de Melo F, Rocha AM, Rocha GA, et al. A regulatory instead of an IL-17 T response predominates in Helicobacter pylori-associated gastritis in children. Microbes Infect. 2012;14:341–347.
34. Boltin D, Niv Y. Ghrelin, Helicobacter pylori and body mass: is there an association? Isr Med Assoc J. 2012;14:130–132.
35. Isomoto H, Nakazato M, Ueno H, et al. Low plasma ghrelin levels in patients with Helicobacter pylori-associated gastritis. Am J Med. 2004;117:429–432.
36. Nishi Y, Isomoto H, Uotani S, et al. Enhanced production of leptin in gastric fundic mucosa with Helicobacter pylori infection. World J Gastroenterol. 2005;11:695–699.
37. Ioannou GN, Weiss NS, Kearney DJ. Is Helicobacter pylori seropositivity related to body mass index in the United States? Aliment Pharmacol Ther. 2005;21:765–772.
38. Redéen S, Petersson F, Törnkrantz E, Levander H, Mårdh E, Borch K. Reliability of diagnostic tests for Helicobacter pylori infection. Gastroenterol Res Pract. 2011;2011:940650.
39. Kazemi S, Tavakkoli H, Habizadeh MR, Emami MH. Diagnostic values of Helicobacter pylori diagnostic tests: stool antigen test, urea breath test, rapid urease test, serology and histology. J Res Med Sci. 2011;16:1097–1104.
40. Mishra S, Singh V, Rao GR, et al. Detection of Helicobacter pylori in stool specimens: comparative evaluation of nested PCR and antigen detection. J Infect Dev Ctries. 2008;2:206–210.
41. Weiss J, Tsang TK, Meng X, et al. Detection of Helicobacter pylori gastritis by PCR: correlation with inflammation scores and immunohistochemical and CLOtest findings. Am J Clin Pathol. 2008;129:89–96.
42. Malfertheiner P, Megraud F, O'Morain CA, et al. Management of Helicobacter pylori infection—the Maastricht IV/ Florence Consensus Report. Gut. 2012;61:646–664.
43. Peterson WL, Graham DY, Marshall B, et al. Clarithromycin as monotherapy for eradication of Helicobacter pylori: a randomized, double-blind trial. Am J Gastroenterol. 1993;88:1860–1864.
44. Malfertheiner P, Mégraud F, O'Morain C, et al. Current European concepts in the management of Helicobacter pylori infection––the Maastricht Consensus Report. The European Helicobacter Pylori Study Group (EHPSG). Eur J Gastroenterol Hepatol. 1997;9:1–2.
45. Donlan RM, Costerton JW. Biofilms: survival mechanisms of clinically relevant microorganisms. Clin Microbiol Rev. 2002;15:167–193.
46. Jain A, Gupta Y, Agrawal R, Khare P, Jain SK. Biofilms–a microbial life perspective: a critical review. Crit Rev Ther Drug Carrier Syst. 2007;24:393–443.
47. Jefferson KK. What drives bacteria to produce a biofilm? FEMS Microbiol Lett. 2004;236:163–173.
48. Stark RM, Gerwig GJ, Pitman RS, et al. Biofilm formation by Helicobacter pylori. Lett Appl Microbiol. 1999;28:121–126.
49. Coticchia JM, Sugawa C, Tran VR, et al. Presence and density of Helicobacter pylori biofilms in human gastric mucosa in patients with peptic ulcer disease. J Gastrointest Surg. 2006;10:883–889.
50. Cellini L, Grande R, Di Campli E, et al. Dynamic colonization of Helicobacter pylori in human gastric mucosa. Scand J Gastroenterol. 2008;43:178–185.
51. Chu YT, Wang YH, Wu JJ, Lei HY. Invasion and multiplication of Helicobacter pylori in gastric epithelial cells and implications for antibiotic resistance. Infect Immun. 2010;78:4157–4165.
52. Necchi V, Candusso ME, Tava F, et al. Intracellular, intercellular, and stromal invasion of gastric mucosa, preneoplastic lesions, and cancer by Helicobacter pylori. Gastroenterology. 2007;132:1009–1023.
53. Malfertheiner P, Selgrad M, Bornschein J. Helicobacter pylori: clinical management. Curr Opin Gastroenterol. 2012;28:608–614.
54. Lesbros-Pantoflickova D, Corthésy-Theulaz I, Blum AL. Helicobacter pylori and probiotics. J Nutr. 2007;137:812S–818S.
55. Gotteland M, Brunser O, Cruchet S. Systematic review: are probiotics useful in controlling gastric colonization by Helicobacter pylori? Aliment Pharmacol Ther. 2006;23:1077–86.
56. Felley C, Michetti P. Probiotics and Helicobacter pylori. Best Pract Res Clin Gastroenterol. 2003;17:785–791.
57. Vandenplas Y, Brunser O, Szajewska H. Saccharomyces boulardii in childhood. Eur J Pediatr. 2009;168:253–265.
58. Lionetti E, Francavilla R, Castellazzi AM, et al. Probiotics and Helicobacter pylori infection in children. J Biol Regul Homeost Agents. 2012;26(1 Suppl):S69–S76.
59. McFarland LV. Systematic review and meta-analysis of Saccharomyces boulardii in adult patients. World J Gastroenterol. 2010;16:2202–2222.
60. Gotteland M, Poliak L, Cruchet S, Brunser O. Effect of regular ingestion of Saccharomyces boulardii plus inulin or Lactobacillus acidophilus LB in children colonized by Helicobacter pylori. Acta Paediatr. 2005;94:1747–1751.
61. Hurduc V, Plesca D, Dragomir D, Sajin M, Vandenplas Y. A randomized, open trial evaluating the effect of Saccharomyces boulardii on the eradication rate of Helicobacter pylori infection in children. Acta Paediatr. 2009;98:127–131.
62. Lasa I. Towards the identification of the common features of bacterial biofilm development. Int Microbiol. 2006;9:21–28.
63. Olmstead S, Allan N, Omar A, Olson M. Evaluation of nutraceutical enzymes in the treatment of clinically significant gastrointestinal biofilms alone and in combination with relevant antibiotics. Poster presented at the 5th Annual American Society for Microbiology Biofilm Meetings; Nov. 2009.
64. Valenti P, Berlutti F, Conte MP, Longhi C, Seganti L. Lactoferrin functions: current status and perspectives. J Clin Gastroenterol. 2004;38(6 Suppl):S127–S129.
65. Singh PK, Parsek MR, Greenberg EP, Welsh MJ. A component of innate immunity prevents bacterial biofilm development. Nature. 2002;417:552–555.
66. Di Mario F, Aragona G, Dal Bò N, et al. Use of bovine lactoferrin for Helicobacter pylori eradication. Dig Liver Dis. 2003;35:706–710.
67. Zou J, Dong J, Yu XF. Meta-analysis: the effect of supplementation with lactoferrin on eradication rates and adverse events during Helicobacter pylori eradication therapy. Helicobacter. 2009;14:119–127.
68. Cammarota G, Branca G, Ardito F, et al. Biofilm demolition and antibiotic treatment to eradicate resistant Helicobacter pylori: a clinical trial. Clin Gastroenterol Hepatol. 2010;8:817–820.e3.
69. Boots AW, Haenen GR, Bast A. Health effects of quercetin: from antioxidant to nutraceutical. Eur J Pharmacol. 2008;585:325–337.
70. Bischoff SC. Quercetin: potentials in the prevention and therapy of disease. Curr Opin Clin Nutr Metab Care. 2008;11:733–740.
71. Brown JC, Jiang X. Activities of muscadine grape skin and polyphenolic constituents against Helicobacter pylori. J Appl Microbiol. Epub 2013 Jan 7.
72. González-Segovia R, Quintanar JL, Salinas E, Ceballos-Salazar R, Aviles-Jiménez F, Torres-López J. Effect of the flavonoid quercetin on inflammation and lipid peroxidation induced by Helicobacter pylori in gastric mucosa of guinea pig. J Gastroenterol. 2008;43:441–447.
Stephen Olmstead, MD, is chief science officer at ProThera Inc., where he directs clinical trials of ProThera and Klaire Labs nutraceutical products. His current research focus is the use of enzymes and chelating agents to disrupt pathogenic GI biofilm. Dr. Olmstead graduated from the University of New Mexico with distinction in biology and chemistry. He attended the University of New Mexico School of Medicine and trained at Harvard Medical School, Massachusetts General Hospital. He is board certified in both internal medicine and cardiovascular diseases.
Kathleen Burns, MSN, RN, NP, senior technical associate at ProThera Inc., provides scientific technical support to ProThera and Klaire Labs health-care professional customers. She received her master's degree in nursing from Massachusetts General Hospital Institute of Health Professions, Boston, and is a board certified pediatric nurse practitioner.
Dennis E. Meiss, PhD, is a founder of ProThera Inc. and acts as president and CEO. He is the primary formulator of ProThera and Klaire Labs products and directs the company's management team. Dr. Meiss received his PhD in neurobiology from the University of Connecticut.
Janet Ralston, BS, is a founder of ProThera Inc. She serves as vice president of the company, where she directs marketing efforts and client service programs. She is a graduate of the University of California, Davis, Nutrition and Dietetics program.