Consensus Details H pylori Testing, Treatment for US Patients

Pam Harrison

March 29, 2018

A new consensus document defining who should be tested and treated for Helicobacter pylori (H pylori) infection has been issued by 11 experts after their participation in the Houston Consensus Conference on Testing for H. pylori Infection in the United States.

The consensus document was published online March 17 in Clinical Gastroenterology and Hepatology.

"The stimulus for this consensus conference was that, despite previous guidelines, recommendations regarding appropriate testing before therapy were commonly not followed, and testing after therapy was also not recommended for practitioners in the United States," Hashem El-Serag, MD, from the Michael E. DeBakey VA Medical Center, Houston, Texas, and colleagues write.

"Clearly, a knowledge gap regarding best practices for H pylori diagnosis and therapy exists even among physicians most likely to be considered experts by their colleagues, and despite regularly updated guidelines, many gaps persist in practice," they add.

Thus, the consensus group singled out target populations who should be considered for testing and treatment, the intention being to provide practical advice for physicians in the United States who manage patients with potential H pylori infection.

Who Should Be Tested?

In terms of which patients should be tested, the panel members unanimously agreed that patients with a history of gastroduodenal ulcers should be tested for H pylori infection, as should those with uninvestigated dyspepsia. The authors note that peptic ulcer disease can be an important sign of underlying H pylori infection. Although eradication of H pylori may not help resolve the dyspepsia, "successful H. pylori eradication therapy will reduce significantly the long-term risk of developing either peptic ulcer or gastric cancer," the panel members write.

The panel members also recommend testing patients who are either first-generation immigrants from a region where the bacterium is highly prevalent, such as Japan or Korea, or are of an ethnic group, such as African Americans or Latinos, that is associated with an elevated infection risk.

In addition, there was strong agreement among panel members that several other groups should be tested, although the supporting evidence is somewhat weaker in these situations. These groups include patients with symptoms of gastroesophageal reflux and patients with gastric MALT lymphoma (alternatively called gastric B-cell lymphoma), together with any patient who has a family history of gastric cancer. As the authors point out, H pylori is typically acquired in childhood and spreads within families, suggesting that first-degree relatives are at higher risk of also being infected and at risk for adverse disease outcomes.

Treatment of H pylori

Panel members strongly agreed that physicians should select an empiric eradication regimen based on antibiotic susceptibility data for either a region or specific to a population. If two attempts to eradicate the infection prove unsuccessful, it is likely the patient is multidrug resistant and that patient should be referred to an expert. For diagnostic testing, the panel also recommends that physicians use a validated stool test or rely on gastric mucosal biopsy to determine antimicrobial susceptibility.

Although H pylori can be successfully eradicated using a number of common antibiotics, practitioners are normally forced to treat empirically because there is no good way of knowing current H pylori resistance patterns in a community. Because of this, exactly what eradication regimen should be used for a given patient should be guided by both the patient's own history of antibiotic use and an awareness of how successful different antibiotic regimens have been in the area.

Physicians should also be aware that resistance to clarithromycin, metronidazole, and the fluoroquinolones has increased in the United States, and that these drugs should not be used as empiric triple therapies. "There are a number of H. pylori treatment regimens that reliably cure at least 95% of infections in adherent patients with susceptible organisms," the panel members note. "The goal should be to reliably identify which regimen is best for an individual patient," they add.

Confirmation of Eradication

As the panel members point out, empiric therapy can fail in at least 20% of patients, and failure to eradicate H pylori renders the patient vulnerable to adverse health outcomes associated with the infection. Thus, the panel members strongly agree that physicians need to use tests such as the urea breath test or stool antigen testing to confirm the bacterium has been successfully treated. "If endoscopy is being performed, biopsies (two each) from the antrum and corpus (+/− the incisura) should be obtained," they add.

In contrast, the panel members do not recommend physicians rely on serology for the detection of active infection because antibodies to the bacterium can remain positive for many years after H pylori eradication. Physicians also need to make sure treatment with bismuth, antibiotics, or the proton pump inhibitors has been stopped at least 4 weeks before testing.

Last, panel members caution that if practitioners see no gastric atrophy, metaplasia, or dysplasia on initial biopsy, patients can still develop ulcers or malignancy if infection persists. "Once atrophic gastritis is present the risk of gastric cancer is elevated, and while H pylori eradication may stop the progress of gastritis and thus reduce or limit the risk, the current thought is that the clock cannot be reset completely," the experts write. "The lack of a history of symptoms suggestive of extensive damage provides no predictive value of future complications. This provides further support for Statement 1. 'We recommend that all patients with active H. pylori infection be treated.' "

The study was funded by a grant from Otsuka America Pharmaceutical, Inc. El-Serag has disclosed no relevant financial relationships. One coauthor reports being an author of several topics for UpToDate. Another coauthor reports serving as a consultant for RedHill Biopharma, BioGaia, and Takeda. He also reports receiving research support for culture of H pylori and, acting as the principal investigator of an international study of the use of antimycobacterial therapy for Crohn's disease. The other coauthors have disclosed no relevant financial relationships.

Clin Gastroenterol Hepatol. Published online March 17, 2018. Abstract

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