Do you empirically treat for Helicobacter pylori (H. pylori) after an upper endoscopy (EGD)?

From the Guidelines

Empirical treatment for H. pylori after an upper endoscopy (EGD) is recommended, especially in high-risk populations, as it can prevent recurrent hemorrhage and reduce the risk of gastric cancer. According to the most recent study 1, a proactive approach to testing and treatment of H. pylori is now recommended, including outreach to family members of individuals diagnosed with active infection as well as high-risk local populations.

When considering empirical treatment, it's essential to note that the prevalence of H. pylori infection in patients with peptic ulcer bleeding appears to be lower than in patients with uncomplicated peptic ulcer disease, varying from 43% to 56% in recent European studies 1. However, empirical treatment of H. pylori infection in patients with bleeding peptic ulcer, immediately after feeding is restarted, is considered the most cost-effective strategy for preventing recurrent hemorrhage.

Some key points to consider when empirically treating H. pylori after an EGD include:

• Abandoning empiric use of clarithromycin, metronidazole, and levofloxacin triple therapies due to increasing antimicrobial resistance 1
• Adopting the principles of antibiotic usage and antimicrobial stewardship to ensure effective treatment and reduce unnecessary antibiotic use
• Confirming eradication with a urea breath test or stool antigen test performed at least 4 weeks after therapy and after stopping PPI for at least 2 weeks

Overall, empirical treatment for H. pylori after an EGD can be an effective strategy for preventing recurrent hemorrhage and reducing the risk of gastric cancer, especially in high-risk populations. However, it's crucial to consider the latest guidelines and recommendations, such as those outlined in the 2022 study 1, to ensure the most effective and safe treatment approach.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of amoxicillin and other antibacterial drugs, amoxicillin should be used only to treat infections that are proven or strongly suspected to be caused by bacteria Eradication of H. pylori has been shown to reduce the risk of duodenal ulcer recurrence.

The decision to empirically treat for H. pylori after an upper endoscopy (EGD) depends on the presence of an ulcer or symptoms suggestive of H. pylori infection.

• If an ulcer is present, treatment for H. pylori is recommended to reduce the risk of duodenal ulcer recurrence.
• However, the FDA drug labels do not provide explicit guidance on empirical treatment for H. pylori after an upper endoscopy (EGD) in the absence of an ulcer or symptoms. Based on the available information, a conservative clinical decision would be to treat for H. pylori if an ulcer is present, but not to empirically treat in the absence of an ulcer or symptoms suggestive of H. pylori infection 2, 3.

From the Research

Empirical Treatment for Helicobacter pylori (H. pylori) Infection

• The empirical treatment for H. pylori infection typically consists of a combination of antibiotics and a proton pump inhibitor (PPI) 4, 5, 6, 7.
• The choice of antibiotics is based on trials in which the primary endpoint was a negative urea breath test, which is an acceptable surrogate criterion 4.
• In previously untreated patients, the first-choice empirical treatment consists of three antibiotics: amoxicillin, clarithromycin, and metronidazole, plus a PPI 4.
• The efficacy of empirical treatment regimens can be affected by antibiotic resistance, with some studies showing that prolonging treatment with a PPI + amoxicillin + clarithromycin or a PPI + amoxicillin + metronidazole to 10 or 14 days improves the rate of H. pylori eradication by 5% to 10% 4.
• Quadruple therapy (PPI, a bismuth salt, metronidazole, and tetracycline) is a very effective second-line regimen in cases of treatment failure 6.

Comparison of Empirical and Susceptibility-Guided Treatment

• The evidence available to date supporting susceptibility-guided therapy for H. pylori infection is limited 8.
• Susceptibility-guided treatment is not better than empirical treatment of H. pylori infection in first-line therapy if the most updated quadruple regimens are empirically prescribed 8.
• Cumulative H. pylori eradication rate with several successive rescue therapies empirically prescribed reaches almost 100% 8.
• The cost-effectiveness of susceptibility-guided treatment has achieved contradictory results in studies 8.

Treatment Regimens and Antibiotic Resistance

• Rising antibiotic resistance has complicated the management of H. pylori, with clarithromycin and levofloxacin therapies should be avoided except when treating a strain of known susceptibility 7.
• Bismuth-based quadruple therapy remains the standard initial empiric regimen, although a rifabutin-based triple regimen is another approach for empiric therapy in the United States 7.
• Knowing local resistance patterns and/or using practice-based eradication rates is important for devising logic-based clinical choices 7.