What is Helicobacter pylori (H. pylori)?

From the Guidelines

The most effective treatment for H. pylori infection is a 14-day bismuth quadruple therapy, which is recommended as the first-line therapy when susceptibility testing or regional data are not available or for a non-invasive test, as stated in the 2019 Gastroenterology study 1.

H. pylori Treatment Overview

H. pylori is a spiral-shaped bacterium that infects the stomach lining, causing chronic inflammation and potentially leading to conditions like gastritis, peptic ulcers, and gastric cancer. The goal of treatment is to eradicate the infection and reduce the risk of these complications.

Current Treatment Guidelines

The current treatment guidelines for H. pylori infection recommend a combination therapy, typically consisting of two antibiotics and a proton pump inhibitor. However, the increasing resistance to antibiotics has led to a shift towards quadruple therapy, which includes bismuth subsalicylate, as recommended in the 2019 Gastroenterology study 1 and supported by the 2022 Annual Review of Medicine study 1.

Importance of Susceptibility Testing

Susceptibility testing is crucial in guiding the selection of therapeutic regimens, especially in areas with high antibiotic resistance. However, the 2019 Gastroenterology study 1 notes that individual susceptibility testing is generally only advised after second-line treatment failure due to cost and logistical constraints.

Future Directions

The management of H. pylori infection is undergoing a transformation, with a focus on delivering effective therapy and achieving high cure rates, as discussed in the 2022 Annual Review of Medicine study 1. The future of H. pylori treatment will likely involve the development of locally effective therapies, feedback loops to monitor treatment outcomes, and the optimization of treatment regimens to achieve cure rates of at least 90%, preferably ≥95%.

Key Considerations

• Bismuth quadruple therapy is recommended as the first-line therapy when susceptibility testing or regional data are not available or for a non-invasive test, as stated in the 2019 Gastroenterology study 1.
• Susceptibility testing is crucial in guiding the selection of therapeutic regimens, especially in areas with high antibiotic resistance.
• Treatment outcomes should be monitored to ensure high cure rates and to adjust treatment regimens as needed.
• The development of locally effective therapies is essential in achieving high cure rates and reducing the risk of antibiotic resistance.

From the Research

H pylori Treatment Options

• The combination of a proton pump inhibitor (PPI) such as omeprazole with amoxicillin and clarithromycin is one of the most effective treatments for the eradication of Helicobacter pylori 2.
• A 1-week course of famotidine, amoxicillin, and clarithromycin is a highly effective, simple, and safe eradication regimen, with an eradication rate of 90.4% 2.
• For first-line treatment, clarithromycin triple therapy should be confined to patients with no previous history of macrolide exposure who reside in areas where clarithromycin resistance amongst H. pylori isolates is known to be low 3.
• Bismuth quadruple therapy or concomitant therapy consisting of a PPI, clarithromycin, amoxicillin, and metronidazole are recommended as first-line treatments for H. pylori infection 3.

Eradication Rates and Treatment Efficacy

• High-dose omeprazole plus amoxicillin or clarithromycin cures H. pylori infection in duodenal ulcer disease, with cure rates of 87.5% and 84.0%, respectively 4.
• A 2-week treatment with omeprazole plus amoxicillin or clarithromycin is highly and equally effective in curing H. pylori infection in patients with duodenal ulcer disease 4.
• The efficacy of triple therapy containing clarithromycin is declining due to increasing antibiotic resistance of H. pylori, making it necessary to select the most appropriate regimen depending on resistance 5.

Treatment Strategies and Recommendations

• Bismuth quadruple therapy and nonbismuth quadruple therapies are some first-line regimen options in regions suspected to have high clarithromycin resistance 5.
• Tailored therapy based on antibiotic sensitivity testing would be optimal, but has several limitations for clinical use, and an alternative technique is required 5.
• The recommended first-line treatment is a proton pump inhibitor combined with amoxicillin and clarithromycin, but rates of eradication with this regimen are falling due to antibiotic resistance and poor compliance with therapy 6.
• Bismuth-based quadruple therapies and levofloxacin-based regimes have been shown to be effective second-line regimens, and third-line options include regimes based on rifabutin or furazolidone 6.