Helicobacter pylori (H. pylori) may enter a non-replicative, non-culturable, low metabolically active state, the so-called coccoid form, to survive in extreme environmental conditions. Since coccoid forms are not susceptible to antibiotics, they could represent a cause of therapy failure even in the absence of antibiotic resistance, i.e., relapse within one year. Furthermore, coccoid forms may colonize and infect the gastric mucosa in animal models and induce specific antibodies in animals and humans. Their detection is hard, since they are not culturable. Techniques, such as electron microscopy, polymerase chain reaction, loop-mediated isothermal amplification, flow cytometry and metagenomics, are promising even if current evidence is limited. Among the options for the treatment, some strategies have been suggested, such as a very high proton pump inhibitor dose, high-dose dual therapy, N-acetycysteine, linolenic acid and vonoprazan. These clinical, diagnostic and therapeutic uncertainties will represent fascinating challenges in the future.

Nearly half of the global population are carriers of Helicobacter pylori (H. pylori), a Gram-negative bacterium that persists in the healthy human stomach. H. pylori can be a pathogen and causes development of peptic ulcer disease in a certain state of the macroorganism. It is well established that H. pylori infection is the main cause of chronic gastritis and peptic ulcer disease (PUD). Decontamination of the gastric mucosa with various antibiotics leads to H. pylori elimination and longer remission in this disease. However, the reasons for repeated detection of H. pylori in recurrent PUD after its successful eradication remain unclear. The reason for the redetection of H. pylori in recurrent PUD can be either reinfection or ineffective anti-Helicobacter therapy. The administration of antibacterial drugs can lead not only to the emergence of resistant strains of microorganisms, but also contribute to the conversion of H. pylori into the resting (dormant) state. The dormant forms of H. pylori have been shown to play a potential role in the development of relapses of PUD. The paper discusses morphological H. pylori forms, such as S-shaped, C-shaped, U-shaped, and coccoid ones. The authors proposes the classification of H. pylori according to its morphological forms and viability.

The main aim of this work was to study and compare the adhesion of water exposed Helicobacter pylori to six different substrata and correlate any changes in morphology, physiology, ability to form aggregates and cultivability when in the planktonic or in the sessile phase.

The number of total cells adhered for different water exposure times and modifications in the cell shape were evaluated using epifluorescence and scanning electron microscopy, and physiology assessed using Syto9 and propidium iodide (PI) cellular uptake. All abiotic surfaces were rapidly colonized by H. pylori, and colonization appeared to reach a steady state after 96 h with levels ranging from 2.3 x 10(6) to 3.6 x 10(6) total cells cm(-2). Cell morphology was largely dependent on the support material, with spiral bacteria, associated with the infectious form of H. pylori, subsisting in a higher percentage on nonpolymeric substrata. Also, sessile bacteria were generally able to retain the spiral shape for longer when compared with planktonic bacteria, which became coccoid more quickly. The formation of large aggregates, which may act as a protection mechanism against the negative impact of the stressful external environmental conditions, was mostly observed on the surface of copper coupons. However, Syto9 and PI staining indicates that most of H. pylori attached to copper or SS304 have a compromised cell membrane after only 48 h. Cultivability methods were only able to detect the bacteria up to the 2 h exposure-time and at very low levels (up to 500 CFU cm(-2)).

The fact that the pathogen is able to adhere, retain the spiral morphology for longer and form large aggregates when attached to different plumbing materials appeared to point to pipe materials in general, and copper plumbing in particular, as a possible reservoir of virulent H. pylori in water distribution systems. However, the Syto9/PI staining results and cultivability methods indicate that the attached H. pylori cells quickly enter in a nonviable physiological state.

This represents the first study of H. pylori behaviour in water-exposed abiotic surfaces. It suggests that co-aggregation with the autochthonous heterotrophic consortia present in water is necessary for a longer survival of the pathogen in biofilms associated to drinking water systems.

Antimicrobial activity of seven bacteriocins produced by lactic acid bacteria against Helicobacter pylori strains (ATCC 43504, Deutsche Sammlung von Mikroorganismen und Zellkulturen GmbH [DSM] 4867, DSM 9691, and DSM 10242) was investigated in vitro using a broth microdilution assay. The bacteriocins chosen for the study were nisin A; lacticins A164, BH5, JW3, and NK24; pediocin PO2; and leucocin K. Antimicrobial activity of the bacteriocins varied among the H. pylori strains tested, of which strain ATCC 43504 was the most tolerant. Among the bacteriocins tested, lacticins A164 and BH5 produced by Lactococcus lactis subsp. lactis A164 and L. lactis BH5, respectively, showed the strongest antibacterial activity against H. pylori strains. MICs of the lacticins against H. pylori strains, when assessed by the critical dilution micromethod, ranged from 0.097 to 0.390 mg/liter (DSM strains) or from 12.5 to 25 mg/liter (ATCC 43504), supporting the strain-dependent sensitivity of the pathogen. Pediocin PO2 was less active than the lacticins against four strains of H. pylori, and leucocin K was the least active peptide, with no inhibition toward H. pylori ATCC 43504. Anti-Helicobacter activity of lacticin A164 was dependent on initial inoculum size as well as concentration of the bacteriocin added.

Helicobacter pylori is rarely cultured from sites other than the gastric mucosa. The morphology of H. pylori in the stomach and dental plaque of adult dyspeptic patients was investigated to determine whether a difference in morphology at these sites could explain the inability to culture the organism from the oral cavity. Five adult patients attending for an upper gastrointestinal endoscopy were investigated. Dental plaque and gastric antral biopsy samples were analysed by culture and polymerase chain reaction (PCR) both before and after immunomagnetic separation using polyclonal rabbit anti-H. pylori IgG. Bead:bacteria aggregates were then examined by scanning electron microscopy (SEM). Rod and coccoid forms of H. pylori were seen by SEM in all oral and gastric samples which were H. pylori PCR positive. Although rod and coccoid forms have previously been shown to be associated with the gastric mucosa, this is the first time H. pylori cells have been visualized in dental plaque.

Helicobacter pylori infection is the commonest cause of gastritis. Different patterns of immune response to H. pylori infection and characteristics of bacteria are considered to contribute to clinical outcomes.

To determine characteristics of the host H. pylori relationship in subjects with non-ulcer dyspepsia and a histological diagnosis of gastritis.

Thirty-five subjects with chronic gastritis undergoing endoscopy (mean age 53 years, range 24-82, 14 male and 21 female) were studied, none of whom was on nonsteroidal anti-inflammatory drugs or antibiotics. H. pylori infection was determined by rapid urease test (CLOtest), culture, antibody and RT-PCR for Ure C, Cag A and 26 kDa gene and histology. Cytokine production of mucosal IL-6 and IL-8 were measured by ELISA.

Fifteen subjects were positive by CLOtest and/or bacterial culture. In these subjects histology showed numerous helical forms of H. pylori (Group I). Nine subjects were negative by CLOtest, bacterial culture, and mRNA for urease C fragment, but positive by PCR for the 26 kDa protein encoding gene. Histology in these subjects showed the presence of either coccoid forms (four), or scant helical forms (two), or mixed coccoid/helical forms (three) (Group II). Eleven subjects were negative by all methods of detection (Group III). IgG and IgA antibody levels in serum (p<0.05) and gastric tissue culture supernatant (p<0.001) were significantly higher in Group I than those in Group II or III. There were significant differences in the IgG serum and IgA supernatant antibody levels (p<0.01 and p<0.05) when Group II was compared to Group III. Supernatant IL-6 levels were significantly higher in Group I (p<0.01) than those from Groups II and III. IL-8 levels were higher in Group I (p<0.01) and Group II (p<0.05) when compared to Group III.

'H. pylori-negative' gastritis can be associated with a non-urease producing form of H. pylori, with a reduction in both local and systemic antibody levels and mucosal pro-inflammatory cytokines.

To explore the relationship between Helicobacter pylori motility, morphology and phase of growth, bacteria were isolated from antral biopsies of patients with duodenal ulcer or non-ulcer dyspepsia, and grown in liquid medium in batch and continuous culture systems. Motilities and morphologies of H. pylori in different phases of growth were examined with a Hobson BackTracker and by transmission electron microscopy. Morphologies of bacteria grown in vitro were also compared with those of bacteria in antral biopsies from patients with non-autoimmune gastritis. H. pylori had poor motility in lag phase, became highly motile in mid-exponential phase and lost motility in the decline phase of growth. Motilities of bacteria in the same phase of growth from patients with duodenal ulcer or non-ulcer dyspepsia were not significantly different. In the mid/late-exponential phase of growth bacteria had helical morphologies and multiple polar flagella, typical of H. pylori in the gastric mucus layer. In the decline phase of growth bacteria shed flagella, and had precoccoidal or coccoidal morphologies. These findings support the view that helical and coccoidal H. pylori are in different phases of growth with different roles in gastric colonization, indicate that bacterial motility per se is unlikely to be a determinant of H. pylori pathology, and suggest that H. pylori in the antral mucus layer is in a state of continuous (exponential phase) growth.

During the conversion from the bacillary into the coccoid form, Helicobacter pylori organisms are known to change extensively. The aim of this study was to determine some of the changes that occur regarding morphology, intracellular composition and surface properties during the aging of bacteria in vitro.

H. pylori from agar plate cultures of different ages was used in this study. The intracellular composition of the two morphological forms of the bacteria was tested by density centrifugation, DNA extraction and quantitative OD, mRNA and ATP measurements. Immunoblotting was used to observe changes in secreted/superficial protein patterns, and hydrophobicity measurements were used to observe changes in surface properties.

All bacillary H. pylori organisms changed morphology gradually over 10 days of culture. Rods had a higher density than cocci; bacteria stored in PBS had the highest density and bacteria stored in water had the lowest. The quantitative DNA, RNA and ATP content were reduced in the aging bacteria. Fewer immunogenic proteins were expressed, and an increased surface hydrophobicity was observed in the older cultures.

This study highlights several aspects of H. pylori aging in vitro and shows some of the differences that exist between bacillary and coccoid forms. This information is important for understanding the transmission and survival of H. pylori outside the human host, as the degradative changes in the intracellular composition and the surface properties shown here point to dead bacteria, and not to a viable but nonculturable form.

Helicobacter pylori, a human pathogen and type 1 carcinogen, causes gastritis, gastric ulcers and gastric cancer. In vivo, H pylori colonizes only gastric surface cells from the antral and fundal regions of the stomach, and heterotopic or metaplastic gastric epithelium present within the esophagus and duodenum. This review summarizes what is known about the association and consequences of attachment between H pylori and gastric cells in vitro, and compares this to the findings demonstrated in vivo. It has been shown that attachment of H pylori to gastric cells results in cup and pedestal formation and cytoskeleton rearrangement similar to that described for enteropathogenic Escherichia coli. Attachment of H pylori induces additional cellular changes in the host cell, including cytokine responses and induction of signal transduction pathways.

The morphologic conversion of Helicobacter pylori from bacillary to coccoid form was studied by microscopy, viable count on agar plates, and bioluminescence assay of bacterial ATP. When morphologic conversion from bacillary to coccoid form was detected by microscopy, the viable counts and the bacterial ATP decreased. No viable count was found after nine days of incubation, but bacterial ATP was still present. In these cultures in which only the coccoid form of Helicobacter pylori was present, there was no accumulation of extracellular ATP, indicating no leaky cells. During the transition phase from the bacillary to the coccoid form of Helicobacter pylori, the addition of fresh medium increased the intracellular ATP 26-fold. The coccoid form of Helicobacter pylori had a 1000-fold lower ATP level per cell compared to the bacillary form, which indicates a decreased metabolic activity in the coccoid form. Addition of fresh medium to the coccoid cultures from days 9 and 10 increased the ATP level twofold. However, no conversion from coccoid to bacillary form was found in these cultures during prolonged incubation in fresh broth for four weeks. Such conversion needs to be demonstrated before it is proven that the coccoid form of Helicobacter pylori is responsible for transmission and relapse of infection.

The detection of Helicobacter pylori in clinical and environmental samples by PCR sometimes requires removal of polymerase inhibitors. We have used a magnetic immunoseparation technique as pre-PCR treatment to facilitate direct detection of H. pylori in stool and water specimens. Rabbit hyperimmune antiserum was produced and magnetic beads were coated with purified immunoglobulin G, which reacted with and bound to both coccoid and rod-shaped forms of H. pylori. When PCR was applied for the detection of H. pylori from cultured samples, the number of organisms that was required for positive scores varied significantly. For a 3-day culture of H. pylori, samples containing 10(2) bacteria per ml are needed for a positive score; for a 6-day culture, samples containing 10(4) bacteria per ml are needed; and for a 10-day culture, samples containing 10(6) bacteria per ml are needed. These results indicate that the coccoid forms of H. pylori may have a different antigenicity and DNA content and are therefore more difficult to detect by immunomagnetic separation and PCR than the rod-shaped forms. Spiked samples with the addition of feces, spiked water samples, and a patient stool specimen were all scored positive with this technique.