Treatment of Helicobacter pylori Infection
Official guideline of the American College of Gastroenterology.
Treatment
Epidemiology
H. pylori prevalence higher outside of North America → in North America, highest amongst African-Americans, Asian/Hispanic immigrants, and low-income households.
Low quality evidence
Indications to test and treat
Treat if active H. pylori infection.
Strong recommendation
Test if active PUD, history of PUD (unless known H. pylori test of cure), low-grade MALT lymphoma, or history of resected early gastric CA; if positive, then treat.
Strong recommendation
Low quality evidence
Noninvasive testing if age <60 + dyspepsia without alarm features (i.e., dysphagia, weight loss, GIB or anemia); if positive, then treat.
Conditional recommendation
Test with gastric biopsy if functional dyspepsia and undergoing EGD; if positive, then treat (NNT = 14 for cure of functional dysplasia).
Strong recommendation
High quality evidence
Do not test if typical GERD symptoms without PUD; if tested and positive, then offer to treat (effects on GERD symptoms unpredictable).
Strong recommendation
High quality evidence
Consider testing if long-term, low-dose ASA use to reduce risk of GIB; if positive, then treat.
Conditional recommendation
Moderate quality evidence
Test if starting chronic course of NSAIDs (unclear benefit if already on NSAIDs); if positive, then treat.
Strong recommendation
Moderate quality evidence
Test if unexplained iron deficiency anemia; if positive, then treat.
Conditional recommendation
Low quality evidence
Test if adult with ITP; if positive, then treat.
Conditional recommendation
Very low quality evidence
Penicillin allergy testing
If failed 1st line therapy and reports PCN allergy, consider allergy testing → can safely treat most with amoxicillin-containing salvage regimens.
Strong recommendation
Low quality evidence
Recommended 1st line treatment
Consider previous antibiotic exposure(s) prior to treating H. pylori infection.
Conditional recommendation
Moderate quality evidence
Treat with clarithromycin triple therapy (PPI BID + clarithromycin 500 mg/day + amoxicillin 1 g/day or metronidazole 500 mg TID) x 14 days (NNT = 12) where <15% H. pylori clarithromycin resistance and no history of macrolide exposure/PCN allergy.
Conditional recommendation
Moderate quality evidence
Treat with bismuth quadruple therapy (PPI BID + bismuth subcitrate 120–300 mg/day + tetracycline 500 mg/day + a nitroimidazole [e.g. metronidazole 500 mg TID]) x 14 days if high clarithromycin resistance or hx of macrolide exposure/PCN allergy.
Strong recommendation
Low quality evidence
Suggested 1st line treatment
Sequential therapy (PPI BID + amoxicillin 1 g BID x 5-7 days, then PPI BID + clarithromycin 500 mg BID + a nitroimidazole BID x 5-7 days) is a suggested 1st line option.
Conditional recommendation
Low quality evidence
Hybrid therapy (concomitant + sequential) with PPI + amoxicillin x 7 days, then PPI + amoxicillin + clarithromycin + a nitroimidazole x 7 days is a suggested 1st line option.
Conditional recommendation
Low quality evidence
Concomitant therapy (PPI BID + clarithromycin 500 mg BID + amoxicillin 1 g BID + a nitroimidazole) x 10-14 days is a 1st line option in North America.
Strong recommendation
Low quality evidence
Omeprazole 40 mg, rifabutin 50 mg, and amoxicillin 1000 mg TID X14 days.
Treatment success - testing
Test of cure = negative urea breath, fecal antigen, or biopsy-based test >4 weeks after antibiotic completion and >1 week after holding PPI.
Strong recommendation
Moderate quality evidence
Successful eradication
Successful H. pylori eradication is highly influenced by sensitivity to antibiotic regimen and adherence to multidrug regimen.
Moderate quality evidence
Resistance - what is known
H. pylori resistance info is scarce → clarithromycin ~16-30%, metronidazole ~20%, levofloxacin ~19-31% in North America.
Strong recommendation
Low quality evidence
Resistance - testing
H. pylori antibiotic susceptibility can be determined, but testing not widely available.
Strong recommendation
Moderate quality evidence
Salvage therapy
If persistent H. pylori, avoid previously used antibiotic.
Strong recommendation
Moderate quality evidence
If clarithromycin based therapy previously used, recommend bismuth quadruple therapy or levofloxacin salvage regimens; best salvage therapy contingent on previous antibiotic exposure and local antibiotic resistance data.
Conditional recommendation
If previously used bismuth quadruple therapy, recommend clarithromycin or levofloxacin based salvage regimens.
Conditional recommendation
Salvage treatment options include: bismuth quadruple therapy x 14 days.
Strong recommendation
Low quality evidence
Salvage treatment options include: levofloxacin triple regimen x 14 days.
Strong recommendation
Moderate quality evidence
Concomitant therapy (see Recommended 1st line treatment) x 10–14 days.
Conditional recommendation
Very low quality evidence
Do not repeat clarithromycin triple therapy.
Conditional recommendation
Low quality evidence
Rifabutin triple regimen (PPI + amoxicillin + rifabutin 300 mg/day) x 10 days.
Conditional recommendation
What do the icons mean?
How strong is the ACG's recommendation?
Factual
Factual statement.Strong recommendation
Intervention's desirable effects clearly outweigh undesirable effects.Conditional recommendation
Uncertainty in tradeoffs between desirable & undesirable effects of intervention.Not a formal recommendation
Not a formal recommendation in ACG CPG 2017.
High quality evidence
Further research is unlikely to change the confidence in estimate of effect.Moderate quality evidence
Further research would be likely to have an impact on the confidence in the estimate of effect.High for efficacy, low for age threshold
Moderate, very low for duration
Low quality evidence
Further research would be expected to have an impact on the confidence in the estimate of effect.Very low quality evidence
Any estimate of effect is very uncertain.Not applicable
Quality of evidence is not applicable.
See salvage treatment options
