With Three Guidelines on H pylori, What Should Clinicians Do?

Helicobacter pylori is a well-recognized infection with global implications for disease state management. Since the initial description of disease implications in the early 1980s, H pylori has been the subject of countless recommendations for best practice management, which have changed sequentially to reflect advances in the scientific knowledge. Three guidelines have been published—the American College of Gastroenterology Clinical Guideline,^[1] the Toronto Consensus,^[2] and the Maastricht V/Florence Consensus Report^[3] (which was updated from an initial report published in 2012). Herein is a brief and general review of some of the changes reflected in them.

Antibiotic Selection

All three recommendations reflect that there is increased resistance to clarithromycin, and traditional triple therapy (clarithromycin + amoxicillin + proton pump inhibitors [PPIs]) should not be prescribed unless the rates of clarithromycin resistance are known to be < 15%. This is a game-changer; for the mainstream practices that do not test for sensitivities for H pylori treatment, we should not use clarithromycin triple therapy.

First-Line Therapy

Quadruple therapy is the new standard. Clarithromycin (500 mg), amoxicillin (1 g), metronidazole (500 mg), and a PPI, all given twice a day, are recommended as first-line therapy. An alternative regimen is bismuth subsalicylate (2 tablets four times a day), metronidazole (500 mg three or four times a day), tetracycline (500 mg four times a day), and a PPI (twice a day). Patients on this regimen will need to be informed about bismuth-related stool darkening. Triple therapy with levofloxacin (500 mg once a day), amoxicillin (1 g twice a day), and a PPI (twice a day) is an alternative but not recommended as the best initial option.

Treatment Duration

Although there was a race for short-course therapy (at one point, a once-a-day regimen), the recommendation is 14 days—which, notably, is different from the product information for an H pylori combination product.

Salvage Therapy for Persistent H pylori Infection

When selecting a salvage therapy, every effort should be taken to avoid antibiotics previously used, and consider whether significant amoxicillin resistance has been reported. Bismuth-based quadruple therapy or levofloxacin triple therapy are accepted salvage regimens. Serum-based tests will probably always be positive and are not a way to diagnose "persistent infection."

New Recommendations for Test and Treat

In patients younger than 60 years with uninvestigated dyspepsia and no alarm features, nonendoscopic testing can be considered. Patients with unexplained iron deficiency should be tested for H pylori. New data on patients with idiopathic thrombocytopenic purpura suggest that, at least in adults, there is sustained improvement of platelet counts after treatment.

Posteradication Testing

Posteradication testing should be performed in all patients, but no sooner than 4 weeks after completion of treatment. When endoscopy is unnecessary, only the urea breath test or fecal antigen testing is acceptable. Bismuth and antibiotics should be withheld for 28 days and PPIs for 7-14 days before urea breath testing. Evidence suggests that fecal antigen testing should not be performed less than 4 weeks (and, in my opinion, preferably 8-12 weeks) after treatment.

Patients on Nonsteroidal Anti-inflammatory Drugs

Eradication of H pylori before starting nonsteroidal anti-inflammatory drugs (NSAIDs) has been shown to significantly reduce the incidence of ulcers and associated complications of bleeding. However, the benefits of treating H pylori in those already taking NSAIDs is less clear.

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