Exercise Guidelines

H. pylori Infection: ACG Updates Handling Recommendations

Key Points for Practice

• Testing for Helicobacter pylori is indicated for certain conditions, such as peptic ulcer disease, and information technology should exist treated in any patient who tests positive.

• Patients should be asked about previous antibiotic exposure to help guide the treatment regimen and avoid failures considering of resistance.

• A urea breath test, fecal antigen testing, or biopsy-based testing should exist used to determine treatment success.

From the AFP Editors

Helicobacter pylori infection is 1 of the most common chronic bacterial infections. The American Higher of Gastroenterology (ACG) has updated its clinical guidelines in response to significant scientific advances in the management of this illness.

Because there is a lack of randomized controlled trials in North America (defined as the United States and Canada in this guideline) that appraise modern treatment regimens, the ACG'due south handling recommendations mostly rely on clinical trial data generated in other parts of the world. These handling recommendations are based on a series of questions.

What Is Known About the Epidemiology of H. pylori Infection in North America? Which Are the High-Risk Groups?

H. pylori infection usually occurs during babyhood, although the ways of acquisition is unclear. Chance factors include low socioeconomic status; increased number of siblings; and having an infected parent, particularly a mother. The incidence and prevalence of the disease are generally higher amidst persons born outside of North America. Within Due north America, it is more mutual in immigrants and in certain racial groups. (in full general, the prevalence is lower among non-Hispanic whites than amongst other groups such as blacks, Hispanics, Native Americans, and Alaska Natives).

What Are the Indications for H. pylori Testing and Treatment?

Testing for H. pylori is indicated in certain patients. Any patient who tests positive for H. pylori infection should be treated.

All patients with agile or previous peptic ulcer disease should exist tested for H. pylori infection unless there is documentation that the infection was previously cured. Patients with low-grade gastric mucosa–associated lymphoid tissue lymphoma or a history of endoscopic resection of early gastric cancer should too be tested. Testing in patients with gastroesophageal reflux disease is not recommended unless the patient has a history of peptic ulcer disease or dyspepsia. If a patient with gastroesophageal reflux affliction is tested and found to take H. pylori infection, treatment should be offered with the acquittance that symptoms of gastroesophageal reflux disease are unlikely to improve.

Based on depression-quality testify, the ACG likewise recommends testing for those initiating long-term nonsteroidal anti-inflammatory drug therapy, those with unexplained atomic number 26 deficiency anemia, and adults with idiopathic thrombocytopenic purpura.

Ideally, tests that identify active infection, such every bit a urea breath test, fecal antigen examination, or endoscopic biopsy, should be used in the diagnosis of H. pylori infection. However, considering the pretest probability of infection is higher in patients with documented peptic ulcer disease, immunoglobulin Grand antibiotic testing is adequate in these patients. Nonendoscopic testing is an option in patients younger than 60 years with uninvestigated dyspepsia without cherry-red flags. If endoscopy is used in patients with dyspepsia, gastric biopsies should be performed.

There is insufficient testify to brand a recommendation near testing and treatment in asymptomatic patients with a family history of gastric cancer or in patients with lymphocytic gastritis, hyperplastic gastric polyps, or hyperemesis gravidarum.

What Are Evidence-Based Get-go-Line Treatment Strategies for Clinicians in North America?

H. pylori is typically treated with a combination of antibiotics plus a proton pump inhibitor (PPI). Patients should be asked about previous antibiotic exposure to help guide the handling regimen. At that place is no regimen with a 100% cure charge per unit for H. pylori infection, and at that place are few, if any, regimens with a ninety% cure rate. The authors used the terms recommended and suggested to express their preferences.

RECOMMENDED

Clarithromycin triple therapy consists of a PPI, clarithromycin (Biaxin), and amoxicillin or metronidazole (Flagyl) for 14 days. The effect of H. pylori resistance to clarithromycin is well documented. Clarithromycin should exist avoided in locations where resistance is greater than 15% and in patients with any previous macrolide exposure.

Bismuth quadruple therapy consists of a PPI, bismuth, tetracycline, and a nitroimidazole for 10 to 14 days. It may be a specially skillful option in patients with macrolide exposure or who are allergic to penicillin. Although metronidazole resistance impacts the effectiveness of this regimen, it is not nearly equally profound every bit with clarithromycin triple therapy. Bismuth quadruple therapy should exist strongly considered equally beginning-line handling where clarithromycin resistance is high or in patients with whatsoever previous macrolide exposure.

Concomitant therapy consists of a PPI, clarithromycin, amoxicillin, and a nitroimidazole (tinidazole [Tindamax] or metronidazole) for 10 to 14 days. This regimen is a promising option that has been shown in international studies to be at least as effective as clarithromycin triple therapy with similar tolerability. Limited data show that the effects of clarithromycin resistance with this regimen are less than with clarithromycin triple therapy. A duration of 10 to fourteen days seems advisable, although studies to assess whether extending therapy to 14 days improves eradication are ongoing.

SUGGESTED

Sequential therapy consists of a PPI and amoxicillin for 5 to vii days followed past a PPI, clarithromycin, and a nitroimidazole for five to seven days. Although 10 days of sequential therapy appears to be a viable culling to 14 days of clarithromycin triple therapy, 10 days of sequential therapy has non been shown to be superior to xiv days of clarithromycin triple therapy. Extending sequential therapy to 14 days may better eradication rates, but more than studies are needed. The complexity of sequential therapy may limit its utilize.

Hybrid therapy, a cross between sequential and concomitant therapies, consists of a PPI and amoxicillin for seven days followed by a PPI, amoxicillin, clarithromycin, and a nitroimidazole for seven days. This regimen is a promising option that has been shown in international studies to exist at to the lowest degree as effective every bit clarithromycin triple therapy with similar tolerability. Although randomized controlled trials showed hybrid therapy to be similar to concomitant therapy, the complication of hybrid therapy may limit its employ.

Levofloxacin triple therapy consists of a PPI, levofloxacin (Levaquin), and amoxicillin for 10 to 14 days. Levofloxacin is a fluoroquinolone with in vitro antimicrobial action confronting gram-positive and gram-negative bacteria, including H. pylori. The few information that exist advise that fluoroquinolone resistance may be as high, if not higher, than clarithromycin resistance in North America. There is besides a lack of information regarding the impact of fluoroquinolone resistance on treatment. Levofloxacin triple therapy for x to 14 days appears to be a comparable culling to clarithromycin triple therapy. The all-time options announced to be fluoroquinolone-containing sequential therapy (a PPI and amoxicillin for v to seven days followed past a PPI, a fluoroquinolone, and nitroimidazole for v to seven days) or LOAD therapy (levofloxacin, omeprazole [Prilosec], nitazoxanide [Alinia], and doxycycline for seven to 10 days).

What Factors Predict Successful Eradication When Treating H. pylori Infection?

Determinants of success can be related to patient factors or to the infection. The master determinants are option of regimen, patient adherence to a multidrug regimen with frequent adverse effects, and the sensitivity of the H. pylori strain to the combination of antibiotics used. The number of doses per day and the severity of adverse effects influence treatment adherence. It is important for physicians to discuss the benefits and challenges of therapy before beginning the regimen. Other patient factors, such as cigarette smoking, diabetes mellitus, and genetics, may also take a role in treatment failure.

Of the infection-related factors, antibody sensitivity was found to be the most important determinant of handling success in clinical trials and population-based studies. Resistance to clarithromycin, metronidazole, and levofloxacin limits their effectiveness and increases the prevalence of H. pylori infection. Resistance to amoxicillin, tetracycline, and rifabutin (Mycobutin) is rare.

What Do We Know Virtually H. pylori Antimicrobial Resistance in North America? What Methods Tin Be Used to Evaluate Resistance, and When Should They Be Used?

Information on resistance are scarce. More research is needed to determine local, regional, and national patterns of H. pylori resistance to antibiotics to guide the choice of regimen.

Resistance tin can be evaluated using culture or molecular testing; however, these methods are not widely available in the United States. Testing through civilisation is hard to perform and takes several days. If successful, cultural methods include agar dilution, disk improvidence, and the E-test. Molecular tests, such as polymerase chain reaction or fluorescently labeled nucleic acid hybridization, are faster, simpler alternatives to culture. However, molecular testing for H. pylori resistance is not currently approved by the U.S. Food and Drug Administration.

The lack of knowledge on H. pylori resistance in the United States is in precipitous contrast to other parts of the earth, creating a barrier to evidence-based treatment recommendations.

Should We Test for Treatment Success Later H. pylori Eradication Therapy?

Because of the failing success rate of H. pylori eradication therapy, persistent infection is not uncommon afterward treatment. A urea breath examination, fecal antigen testing, or biopsy-based testing should be used to make up one's mind handling success. Testing should be performed at least four weeks after completion of antibiotic therapy and after PPI therapy has been withheld for ane to two weeks. Although the recommendation for posttesting is intuitive, the scientific evidence regarding the price-effectiveness of such testing is lacking, except for the scenario of bleeding peptic ulcers.

When First-Line Therapy Fails, What Are the Options for Salvage Therapy?

If infection persists subsequently treatment, the same antibiotics should be avoided when retreating the patient. Bismuth quadruple therapy or levofloxacin regimens are preferred for patients who initially received a regimen containing clarithromycin. A regimen containing clarithromycin or levofloxacin is preferred for patients who initially received bismuth quadruple therapy. Local antimicrobial resistance data and the patient's previous antibiotic exposure should be considered when choosing save therapy. Similar offset-line therapy, the ACG recommendations for salve therapy are based on empiric choice rather than results of culture and antimicrobial sensitivity testing.

Bismuth quadruple therapy (PPI, bismuth, tetracycline, metronidazole) for xiv days or levofloxacin triple therapy (PPI, levofloxacin, amoxicillin) for xiv days are the recommended save regimens. Other suggested regimens include concomitant therapy (PPI, clarithromycin, amoxicillin, nitroimidazole) for 10 to 14 days, rifabutin triple therapy (PPI, amoxicillin, and rifabutin) for 10 days, and loftier-dose dual therapy (PPI and amoxicillin) for xiv days. Clarithromycin triple therapy is not recommended for salvage therapy.

When Should Penicillin Allergy Testing Exist Considered in Patients with H. pylori Infection?

Amoxicillin is an important component of H. pylori treatment regimens. Even so, at that place are alternatives that do not include amoxicillin, about notably bismuth quadruple therapy. Allergy testing may be considered later on 1 or ii failures of offset-line therapy. Most ofttimes, a truthful penicillin allergy will be excluded, and amoxicillin-containing salvage therapy can exist initiated safely.

Guideline source: American College of Gastroenterology

Evidence rating organization used? Aye

Systematic literature search described? Yep

Guideline developed by participants without relevant fiscal ties to industry? No

Recommendations based on patient-oriented outcomes? Yes

Published source: Am J Gastroenterol. February 2017;112(ii):212–239

Available at: https://world wide web.nature.com/ajg/journal/v112/n2/full/ajg2016563a.html [login required]

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Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This serial is coordinated by Sumi Sexton, MD, Associate Deputy Editor.

A collection of Exercise Guidelines published in AFP is available at http://www.aafp.org/afp/practguide.

Copyright © 2018 by the American University of Family unit Physicians.
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