The Changes Made in the New Expert Consensus on H pylori

Nathalie Raffier

November 15, 2022

VIENNA ― Experts in Maastricht, the Netherlands, have updated the 2017 Helicobacter pylori consensus report, now referred to as the Maastricht VI/Florence Consensus Report. Published in August 2022, the document and its changes were recently addressed at the 30th United European Gastroenterology Week in Vienna, Austria.

H pylori Gastritis Is an Infectious Disease

H pylori infects more than half of the world's population. This infectious disease is now included in the 11th revision of the International Classification of Diseases, which, in principle, recommends that all infected patients receive treatment.

H pylori causes gastritis, regardless of its symptoms or complications. It is involved in the development of peptic ulcers, dyspepsia, and stomach cancers (adenocarcinoma and MALT lymphoma). It can also be involved in some iron deficiency anemias, vitamin B12 deficiency, and idiopathic thrombocytopenic purpura.

Test-and-Treat: Is This the Right Strategy for Uninvestigated Dyspepsia?

Although this strategy has not been approved in France, owing to the low cost of gastrointestinal (GI) endoscopies, experts are recommending the use of the so-called "test-and-treat" strategy for patients younger than 50 years who have uninvestigated symptoms of dyspepsia and have no alarm symptoms. In dyspeptic patients older than 50 (45–55) years, particularly patients with coexisting risk factors, upper GI endoscopy is recommended.

A positive noninvasive diagnostic test (serology, urea breath test, stool antigen tests) should prompt H pylori eradication therapy, without routine use of endoscopy.

In Areas Where the Prevalence of H pylori Is Low, Endoscopy Is Not Needed in the Initial Dyspepsia Investigation

Patients whose symptoms are linked to a peptic ulcer or H pylori–associated dyspepsia will experience a marked improvement once H pylori has been eradicated. Only patients whose symptoms persist should be referred for GI endoscopy. In the event of a normal endoscopy exam and persistent symptoms of dyspepsia despite H pylori eradication, a diagnosis of functional dyspepsia may be made.

Empirical Antibiotic Treatments Should Be Avoided as Much as Possible

Antibiotic susceptibility is a key consideration. For a long time, it required difficult bacteriologic cultures that were available only from a limited number of expert centers.

Nowadays, simple, quick molecular biology techniques, available in most bacteriology laboratories, can be used to reliably assess the resistance of H pylori to macrolides, quinolones, rifampicin, and tetracycline (by detecting genetic mutations of the strain that is resistant to the antibiotics).

In view of the current availability of these molecular biology techniques, the Maastricht experts strongly recommend testing H pylori strains so that antibiotic therapies can be proposed as the first line of treatment and so that the empirical use of antibiotics can be avoided as much as possible.

Eradication must still be checked at least 1 month after treatment is complete. To this end, the patient should not take proton pump inhibitors (PPIs) in the 14 days prior to the eradication test.

Bismuth-Based Quadruple Therapy Is Recommended as First-Line Treatment in France

The 2022 version of the Maastricht recommendations has set out the data for the deciding on first-line treatment. If the strain cannot be tested, the treatment strategy depends on the level of resistance to macrolides in the region or country in question. Thus, in regions where macrolide resistance is greater than 15% (it's 20% in France), a bismuth-based quadruple therapy is recommended as first-line treatment. This treatment consists of omeprazole, bismuth salt, tetracycline, and metronidazole.

Although most studies have shown that treatment can be as short as 10 days, experts are recommending 14 days of treatment.

When a nonbismuth quadruple therapy is required, concomitant therapy lasting 14 days that combines a PPI, amoxicillin, clarithromycin, and metronidazole is recommended.

If one of these two first-line treatments is unsuccessful, the option not initially selected should be prescribed as second-line treatment. Alternatively, a quinolone-based treatment could be proposed.

Beyond these two lines of treatment, it is essential to conduct an analysis of antibiotic susceptibility in order to choose a quinolone or rifampicin-based treatment. These recommendations will have to be approved and adapted to the situation in France.

Eradication of H pylori and Cancer

H pylori is the major cause of gastric carcinogenesis. For patients with localized, low-grade MALT gastric lymphoma, H pylori eradication therapy is indicated as first-line therapy, even if the infection cannot be documented and the diagnostic tests are negative.

Regarding adenocarcinoma, the situation is more complex. Indeed, H pylori gradually causes severe atrophic gastritis and intestinal metaplasia that may become dysplastic and develop into an adenocarcinoma.

However, once the patient has reached the stage of severe atrophic gastritis, the benefits of eradication are uncertain, as lesions are rarely reversible. Therefore, experts stress that although the benefit of eradicating H pylori for preventing cancer applies to all adults, the benefit decreases with age and progression of gastric mucosal lesions.

Interventional studies conducted in Asia have demonstrated the benefit of eradicating H pylori after treatment of stomach cancer in preventing the development of a second metachronous cancer.

Should H pylori infection screening campaigns be promoted to prevent stomach cancer in the way that is done for bowel cancer? The answer to this is not clear-cut and depends on the local incidence of stomach cancer. It is important not to neglect the potential impact of large-scale antibiotic treatments in increasing antibiotic resistance.

Experts have nonetheless reaffirmed that "test-and-treat" screening campaigns were cost-effective in countries where the incidence of stomach cancer was average or high.

The Impact of H pylori and Its Treatments on the Microbiota

Pediatricians do not recommend routine eradication of H pylori in children, owing to the impact it may have on the development of certain conditions, especially allergies, via the effect of the antibiotics on the gut microbiota.

The harmful role of repeated courses of antibiotics in childhood on the resistance of H pylori strains in adulthood is highlighted. This is especially true, particularly in France, regarding macrolide resistance.

Probiotics may reduce the side effects of antibiotics (eg, diarrhea) and thus improve the rates of eradication by promoting better drug compliance.

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