H.pylori gastritis guideline recommendation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]

Overview

American collage of gastroenterology guidelines for the management of Helicobacter pylori infection.

ACG recommendations

Diagnosis

Recommendation
Testing for H. pylori infection is indicated in patients with active peptic ulcer disease, a past history of documented peptic ulcer, or gastric MALT lymphoma.
The test-and-treat strategy for H. pylori infection is a proven management strategy for patients with uninvestigated dyspepsia who are under the age of 55 yr and have no “alarm features” (bleeding, anemia, early satiety, unexplained weight loss, progressive dysphagia, odynophagia, recurrent vomiting, family history of GI cancer, previous esophagogastric malignancy).

Indications for Diagnosis and Treatment of H.pylori Infection
Established
Active peptic ulcer disease (gastric or duodenal ulcer)
Confirmed history of peptic ulcer disease (not previously treated for H. pylori)
Gastric MALT lymphoma (low grade)
After endoscopic resection of early gastric cancer
Uninvestigated dyspepsia (depending upon H. pylori prevalence)
Controversial
Nonulcer dyspepsia
Gastroesophageal reflux disease
Persons using nonsteroidal antiinflammatory drugs
Unexplained iron deficiency anemia
Populations at higher risk for gastric cancer

Diagnostic Testing for H.pylori Infection

• Testing for H.pylori should only be performed if the clinician plans to offer treatemnt for positive results.
• Deciding which test to use in which situation relies heavily upon whether a patient requires evaluation with upper endoscopy and an understanding of the strengths, weaknesses, and costs of the individual tests.

Endoscopic testing	Advantages	Disadvantages
*1. Histology	Excellent sensitivity and specificity	Expensive and requires infrastructure and trained personnel
*2. Rapid urease testing	Inexpensive and provides rapid results. Excellent specificity and very good sensitivity in properly selected patients	Sensitivity significantly reduced in the posttreatment setting
*3. Culture	Excellent specificity. Allows determination of antibiotic sensitivities	Expensive, difficult to perform, and not widely available. Only marginal sensitivity
*4. Polymerase chain reaction	Excellent sensitivity and specificity. Allows determination of antibiotic sensitivities	Methodology not standardized across laboratories and not widely available
Nonendoscopic testing	Advantages	Disadvantages
1. Antibody testing (quantitative and qualitative)	Inexpensive, widely available, very good NPV	PPV dependent upon background H. pyloriprevalence. Not recommended after H. pyloritherapy
*2. Urea breath tests (13C and 14C)	Identifies active H. pylori infection. Excellent PPV and NPV regardless of H. pylori prevalence. Useful before and after H. pylori therapy	Reimbursement and availability remain inconsistent
*3. Fecal antigen test	Identifies active H. pylori infection. Excellent positive and negative predictive values regardless of H. pylori prevalence. Useful before and after H. pylori therapy	Polyclonal test less well validated than the UBT in the posttreatment setting. Monoclonal test appears reliable before and after antibiotic therapy. Unpleasantness associated with collecting stool
*The sensitivity of all endoscopic and nonendoscopic tests that identify active H. pylori infection is reduced by the recent use of PPIs, bismuth, or antibiotics PPI = proton pump inhibitor; PPV = positive predictive value; NPV = negative predictive value; UBT = urea breath test.

Treatment of H.pylori Infection

Primary Treatment of H.pylori Infection
In the United States, the recommended primary therapies for H. pylori infection include: a PPI, clarithromycin, and amoxicillin, or metronidazole (clarithromycin-based triple therapy) for 14 days or a PPI or H2RA, bismuth, metronidazole, and tetracycline (bismuth quadruple therapy) for 10–14 days.
Sequential therapy consisting of a PPI and amoxicillin for 5 days followed by a PPI, clarithromycin, and tinidazole for an additional 5 days may provide an alternative to clarithromycin-based triple or bismuth quadruple therapy but requires validation within the United States before it can be recommended as a first-line therapy.

First-Line Regimens for Helicobacter pylori Eradication
Regimen	Duration	Eradication Rates	Comments
Standard dose PPI b.i.d. (esomeprazole is q.d.), clarithromycin 500 mg b.i.d., amoxicillin 1,000 mg b.i.d.	10–14	70–85%	Consider in nonpenicillin allergic patients who have not previously received a macrolide
Standard dose PPI b.i.d., clarithromycin 500 mg b.i.d. metronidazole 500 mg b.i.d.	10–14	70–85%	Consider in penicillin allergic patients who have not previously received a macrolide or are unable to tolerate bismuth quadruple therapy
Bismuth subsalicylate 525 mg p.o. q.i.d. metronidazole 250 mg p.o. q.i.d., tetracycline 500 mg p.o. q.i.d., ranitidine 150 mg p.o. b.i.d. or standard dose PPI q.d. to b.i.d.	10–14	75–90%	Consider in penicillin allergic patients
PPI + amoxicillin 1 g b.i.d. followed by:	5	>90%	Requires validation in North America
PPI, clarithromycin 500 mg, tinidazole 500 mg b.i.d.	5
PPI = proton pump inhibitor; pcn = penicillin; p.o. = orally; q.d. = daily; b.i.d. = twice daily; t.i.d. = three times daily; q.i.d. = four times daily. *Standard dosages for PPIs are as follows: lansoprazole 30 mg p.o., omeprazole 20 mg p.o., pantoprazole 40 mg p.o., rabeprazole 20 mg p.o., esomeprazole 40 mg p.o. Note: the above recommended treatments are not all FDA approved. The FDA approved regimens are as follows: 1. Bismuth 525 mg q.i.d. + metronidazole 250 mg q.i.d. + tetracycline 500 mg q.i.d. × 2 wk + H2RA as directed × 4 wk. 2. Lansoprazole 30 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days. 3. Omeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days. 4. esomeprazole 40 mg q.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days. 5. Rabeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 7 days.

Salvage Therapy for Persistent H.pylori Infection

• In patients with persistent H.pylori infection, every effort should be made to avoid antibiotics that have been previously taken by the patient.
• Bismuth-based quadruple therapy for 7-14 days is an accepted salvage therapy.
• Levofloxacin-based triple therapy for 10 days is another option in patients with persistent infection, which requires validation in the United States.

Recommendations
Regimen	Duration	Eradication Rates	Comments
Bismuth quadruple therapy PPI q.d. tetracycline, Pepto Bismol, metronidazole q.i.d.	7	68% (95% CI 62–74%)	Accessible, cheap but high pill count and frequent mild side effects
Levofloxacin triple therapy PPI, amoxicillin 1 g b.i.d., levofloxacin 500 mg q.d.	10	10 87% (95% CI 82–92%)	Requires validation in North America
For recommendations regarding rifabutin and furazolidone, please refer to the text. PPI = proton pump inhibitor; q.d. = daily; q.i.d. = four times daily; b.i.d. = twice daily.