Is Helicobacter pylori (H. pylori) transmissible and how is it treated?

H. pylori Transmission and Treatment

Yes, Helicobacter pylori is transmissible from person to person primarily through oral-oral or fecal-oral routes, and the recommended first-line treatment is 14-day bismuth quadruple therapy in areas with high clarithromycin resistance. 1, 2

Transmission of H. pylori

• H. pylori is one of the world's most common pathogens, colonizing approximately 50-60% of the world's population 1, 3
• The primary mode of transmission is person-to-person, occurring through:
  • Oral-oral route (through vomitus or possibly saliva) 1
  • Fecal-oral route 1
• Waterborne transmission may occur, especially in areas with untreated water due to fecal contamination 1
• Iatrogenic transmission following endoscopy is the only definitively proven mode of transmission 1
• Higher infection rates are observed in:
  • Developing countries compared to developed countries 1
  • Childhood (especially in developing countries) 3
  • Crowded or high-density living conditions 1
  • Institutional settings (clustering of infection) 1

Treatment Recommendations

First-line Treatment

• 14-day bismuth quadruple therapy is the preferred first-line empirical treatment in areas with high clarithromycin resistance (>15-20%) 2, 4
• In areas with low clarithromycin resistance (<15%), PPI-clarithromycin-amoxicillin or PPI-clarithromycin-metronidazole triple therapy for 14 days can be used 2
• High-dose PPI (twice daily) increases treatment efficacy:
  • 40 mg of rabeprazole or esomeprazole twice daily is recommended 2, 4
  • Pantoprazole should be avoided due to lower relative potency 4

Second-line Treatment

• After failure of PPI-clarithromycin-containing therapy, either:
  • Bismuth-containing quadruple therapy, or
  • Levofloxacin-containing triple therapy 2
• Rising rates of levofloxacin resistance should be considered when selecting second-line therapy 2

Third-line Treatment

• After failure of second-line therapy, treatment should be guided by antimicrobial susceptibility testing whenever possible 2, 5
• Rifabutin triple therapy for 14 days is an option for patients who have failed previous treatments 2, 6

Special Populations

Patients with Penicillin Allergy

• In areas of low clarithromycin resistance, PPI-clarithromycin-metronidazole combination is recommended 2
• In areas of high clarithromycin resistance, bismuth-containing quadruple therapy is preferred 2

Confirmation of Eradication

• Confirmation of H. pylori eradication should be performed at least 4 weeks after completing treatment 2
• Non-invasive tests such as urea breath test (UBT) or validated monoclonal stool test are recommended 2
• Endoscopy-based testing is necessary for patients with complicated peptic ulcer disease, gastric ulcer, and MALT lymphoma 2

Clinical Considerations and Pitfalls

• Antibiotic resistance is the most important factor responsible for declining success rates of H. pylori eradication treatment 2, 4
• Patient compliance is crucial for successful eradication 2
• Avoid using antibiotics to which the patient has been previously exposed 2, 7
• Treatment duration of at least 14 days improves eradication rates compared to 7-day regimens 2, 6
• H. pylori eradication has been shown to reduce the risk of duodenal ulcer recurrence and may have a prophylactic effect against gastric cancer 7, 6

Indications for H. pylori Eradication

• All patients with peptic ulcer disease (active or history) 2, 8
• First-degree relatives of family members with gastric cancer 2
• Patients with previous gastric neoplasia treated by endoscopic or subtotal gastric resection 2
• Patients with severe pan-gastritis, corpus-predominant gastritis, or severe atrophy 2