Multiple and mixed Helicobacter pylori infections: Comparison of two epidemiological situations in Tunisia and France

Individuals can be infected by either a single or multiple strains of Helicobacter pylori. Multiple infection with genetically different isolates and particularly mixed infection with both antibiotic-susceptible and resistant isolates are difficult to detect and should impact the effectiveness of eradication treatment. It is largely assumed that multiple infections are more frequent in developing countries but an actual comparison developing/developed using a single methodology has never been reported. To compare the prevalence of multiple and mixed H. pylori infection in Tunisia and France, we conducted a prospective study including 42 H. pylori-culture positive infected patients (21 Tunisian and 21 French) never previously treated for H. pylori infection. One gastric biopsy was collected from antrum. Three to eleven (mean = 9) colonies were isolated from each biopsy. A total of 375 different isolates were genotyped using RAPD fingerprinting and antimicrobial susceptibility testing was performed on amoxicillin, clarithromycin, ciprofloxacin, rifampicin, tetracycline and metronidazole with E-tests. Multiple infection was defined by different RAPD fingerprintings among the different isolates from a single patient. Mixed infection was defined by different resistance profiles among the different isolates from a single patient. Multiple H. pylori infection is more prevalent in Tunisia than in France. It occurred in ten (48%) Tunisian patients and in one (5%) French patient (p < 0.001). Mixed infection is common (24%), it occurred in 4 (19%) Tunisian patients and in 6 (29%) French patients (p = 0.46) and was mainly (8/10) due to genetically related clones in single infection.