A retrospective study of potential influence factors on Helicobacter pylori infection treatment


 BackgroundThe high prevalence of Helicobacter pylori (H. pylori) infection has been associated with overcrowding, poor housing, poor sanitation and unclean water supplies in developing countries.MethodsWe assessed records of symptomatic patients attending Southwest Hospital in 2017, collected patients’ information such as age, gender, education levels, income level, number of family members, frequency of hand washing after defecation, past history of gastropathy and so on. Chi square analysis, t-test and Odds Ratio (OR) were used to evaluate the effect of potential factors on treatment effect.ResultsAge, gender, number of family members, follow-up time, type of toilet, water source and past history of gastropathy seemed to be irrelevant to H. pylori infection control. Higher education level was benefit for patients (OR 0.315, 95% CI 0.134-0.741, P=0.008). Less frequency of hands washing after defecation was harmful factors for H. pylori-positive patients’ treatment (OR=3.438, 95% CI 1.679-7.039, P=0.001). Better income status was a protective factor only in Univariate analysis (OR=0.396 95% CI 0.197-0.795, P=0.01).ConclusionA better education background and strict habits of hands washing were both helpful for H. pylori-positive patients’ treatment.


Conclusion
A better education background and strict habits of hands washing were both helpful for H. pylori-positive patients' treatment.

Background
Helicobacter pylori (H. pylori) is a Gram-negative and micro-aerophilic bacteria that colonize in human stomach, and H. pylori infection affects almost half of the world's population (1). As the major risk factor of peptic ulcer diseases, H. pylori was also classi ed as a grade I carcinogen by World Health Organization (2). In fact, its infection lead to duodenal ulcer disease, gastric ulcer disease, gastric adenocarcinoma and gastric lymphoma (3). In addition to digestive diseases, H. pylori infection was also associated with cardiovascular, neurologic, hematologic, head and neck, urogynecologic diseases, as well as diabetes mellitus and metabolic syndrome in the past several years (4,5).
The high prevalence of H. pylori infection in developing countries has been associated with overcrowding, poor housing, poor sanitation and unclean water supplies in some researches (6). Shiferaw et al (7) assessed the symptomatic patients attending at a private clinic from August 2017 until May 2018 in Addis Ababa city, Ethiopia, and found the prevalence of H. pylori infection was 36.8%, which was related to low income and low education levels. Wang et al(8) found in a community in Hebei Province of China, more than half of the population was infected with H. pylori, the socio-demographic pro les, socio-economic factors and lifestyle are potential factors affected on the prevention of diseases associated with H. pylori infection. Takunori et al (9) even found that H. pylori infection is more strongly related to living with one's grandparents than living in a hygienic environment.
Apart from H. pylori resistance, few researches focused on the potential factors affected on H. pylori infection treatment (10,11). Therefore, we conducted a retrospective study on H. pylori infected patients in Southwest Hospital, and collected their income, education, living conditions to nd out their role in H. pylori infection treatment.

Method Study design, period and area
We assessed records of symptomatic patients attending Southwest Hospital between January 1, 2017 and December 31, 2017 with their magnitude of H. pylori. All patients were treated with standard rst-line triple therapy (Proton-pump inhibitor twice daily, 500 mg clarithromycin twice daily, and 1 g amoxicillin twice daily for 7 days). Patients followed up within one year were included in the current study, magnitude of H. pylori was determined again at their rst follow-up to evaluate the treatment effect. Our study was submitted to and approved by Southwest Hospital Ethics Committee.

Information collection
Socio-economic factors and lifestyles information were collected such as age, gender, education levels, income level, number of family members, frequency of hand washing after defecation, past history of gastropathy and so on. Patients' education levels were divided into bachelor degree or above, secondary school or below. Income level were evaluated by family monthly income, and divided into two levels as more than 6,000 RMB and less than 6,000 RMB. Frequency of hand washing after defecation were recorded as every time and occasionally or never.
Determine the magnitude of H. pylori H. pylori infection was evaluated by the 13C urea breath test (13C-UBT) in the morning after fasting for at least 8 h. Breath samples were collected from each subject at baseline and 30 min after drinking 75 mg of 13C-urea in 70 mL room temperature water. The test was performed with a 13C-breath test instrument (Fischer Analysen Instrumente GmbH, Leipzig, Germany), and results were expressed as a surplus of isotopic ratio over baseline (delta over baseline [DOB]). A DOB value of > 4 ‰ was considered positive, according to instructions from test manufacturer.

Statistical analysis
Statistical analyses were performed using Statistical Package for SPSS (Windows version 20.0). Chi square analysis, t-test and Odds Ratio (OR) were used to evaluate the effect of potential factors on treatment effect. Two-sided P value < 0.05 was considered as statistically signi cant.

Result General information
According to inclusion criteria, 149 patients, 84 females and 65 males were included in our analysis, the mean age was 45.2 ± 13.4 years, with a range of 9 to 70 years. As to income level, 37 patients were more than 6,000 RMB, and 112 were less than 6,000 RMB. Forty-six patients lived with one family member, 50 with two members, 35 with three members and 17 lived alone. Forty-one patients were bachelor degree or above, and the rest 108 patients had secondary school degrees or below. Two patients used Pit toilet, and the rest patients used ush toilet at home. Seven patients used puri ed water as drinking water and the other 142 used tap waters. Washing hands after defecation was essential to 67 patients, and 82 patients occasionally or never washed hands after defecation. Ninety-eight patients had a past history of gastropathy and 51 had not. Patients with less than 3000 RMB monthly income were more likely to show H. pylori-positive at their rst follow-up, with OR 2.163 (95%CI 1.101-4.249) and P=0.02. Bachelor degree or above was a protective factor that might help patients to get a better treatment effect, OR 0.396 (95%CI 0.197-0.795) and P=0.01. Washing hands after toilet was also a protect factor that might do good for patients, for the OR for patients not washing hands every time was 3.176 (95%CI 1.616-6.242) and P=0.00 (table 2).

Multivariate analysis
Patients' income level, education level and hands washing habit after defecation were further analyzed by Multivariate regression analysis. As shown in table 3, income level was not a signi cant factor that affect treatment effect, for the OR was 1.25 (95%CI 0.541-2.885) with P=0.601. While higher education level was bene t for patients, and the ORs were 0.315 (95%CI 0.134-0.741), P=0.008. Less frequency of hands washing after defecation was harmful factors for H. pylori-positive patients' treatment, OR=3.438 (95%CI 1.679-7.039), and P=0.001.

Discussion
H. pylori is the cause of acute and chronic gastritis and highly associated to gastric cancer and peptic ulcer (12). The prevalence of H. pylori varies across the globe, which partly due to socioeconomic difference. Although H. pylori infection transmission route is not clearly known, fecal contaminated water and food, fecal-oral contact are considered to be possible sources of infection, according to some evidences (13,14). Helicobacter pylori infection is apparent in resource limited countries than in developed countries and the distribution varies between different communities and geographical locations (15).
In the current research, H. pylori-positive patients were treated with standard rst-line triple therapy (Proton-pump inhibitor twice daily, 500 mg clarithromycin twice daily, and 1 g amoxicillin twice daily for 7 days). H. pylori infection was evaluated again at the rst follow-up, and 43.0% patients were still H. pyloripositive. Related information such as age, gender, education levels, income level, number of family members, frequency of hand washing after defecation and past history of gastropathy were collected to assess their affection on infection treatment.
According to our analysis, monthly income less than 3000 MRB was an unfavorable factor for H. pylori related treatment, which implied that economic conditions were nonnegligible factors to H. pylori infection treatment and control. Meanwhile, better education background, hands washing habits, always associated with better incomes, were both bene cial factors for H. pylori infection treatment. These conclusions were similar to some previous researches (2,16). After multivariate regression analysis, income level was not statistically signi cant, while better education background, hands washing habits were still recognizable.
Age, gender, number of family members, follow-up time, type of toilet, water source and past history of gastropathy seemed to be irrelevant with H. pylori infection control. These results, especially type of toilet and water source were not a statistically signi cant factor on H. pylori infection control, were not consistent with some conclusions before (2), which should be interpreted with caution. Only 2 patients used pit toilet at home, and 7 patients used puri ed water as drinking water source, therefore, inadequate sample size might lead to a biased result.

Conclusion
The current research collected patients' information and analyzed the potential effect of some factors on H. pylori infection control. A better education background and strict hands washing habits were both helpful for H. pylori-positive patients' treatment. Our study was submitted to and approved by Southwest Hospital Ethics Committee.

Availability of data and materials
All data generated or analysed during this study are included in this published article.

Competing interests
The authors declare that they have no con ict of interest.

Funding
This study was funded by Chongqing Technology Innovation and application development project (cstc2019jscx-msxmX0199). The funding body did not play a role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.
Authors' contributions XQ and LX analyzed and interpreted the patient data. LX was a major contributor in writing the manuscript. DH and YY designed the research, and all authors read and approved the nal manuscript.