In settings where susceptibility data are hard to come by, 14 days of bismuth quadruple therapy is likely best for Helicobacter pylori eradication, researchers report. “With three guideline recommendations on H. pylori treatment coming out at around the same time, there may have been some confusion on which to follow,” Dr. Carlo A. Fallone from McGill University Health Center, in Montreal, Canada, told Reuters Health by email. “We reconciled these 3 documents, thus simplifying choices for the clinician.”

Released guidelines

Dr. Fallone and colleagues reviewed recently released guidelines from the European Helicobacter and Microbiota Study Group; the American College of Gastroenterology and the Canadian Association of Gastroenterology/Canadian Helicobacter Study Group to arrive at the best treatment options for H. pylori infection.

Each guideline strongly recommends the use of antibiotic susceptibility data whenever available or obtainable to ensure appropriate antibiotic use and prevent widespread resistance; and the authors endorse that recommendation while recognizing that these data are not available in many parts of the world.

Antibiotic susceptibility

If the antibiotic susceptibility profile is known, first-line treatment should include PPI triple therapy with amoxicillin for clarithromycin-sensitive organisms and bismuth quadruple therapy for clarithromycin-resistant organisms. When the susceptibility profile is unknown; bismuth quadruple therapy or concomitant non-bismuth quadruple therapy is appropriate (depending on the availability of bismuth); the team advises in Gastroenterology; online April 15.

The optimal duration of therapy remains uncertain; but 14 days appears to be reasonable, especially for first-line therapy, the authors say. Every effort should be made to succeed on the first treatment attempt, not only to reduce costs, they add, but also to reduce patient anxiety; negative impacts on other gut microbiota and antibiotic resistance.

Although existing evidence is limited, probiotics might contribute to H. pylori eradication and gut microbiome preservation. Potent acid suppression with potassium-competitive acid blockers might be beneficial in some populations. “When therapy is unsuccessful, it is likely due to resistance to clarithromycin; levofloxacin, and/or metronidazole; these drugs, if previously used, should be avoided in subsequent eradication attempts,” Dr. Fallone said.

Subsequent treatment

“Second-line therapies should be bismuth quadruple therapy or levofloxacin triple therapy, depending on suspected resistance; reserving rifabutin-based triple and high-dose dual amoxicillin-proton pump inhibitor therapy for subsequent treatment attempts.” “I’d like to stress that we definitely require local availability of susceptibility testing for individuals and especially the establishment of regional and national monitoring programs to determine regional resistance rates and thus develop evidence-based locally relevant eradication strategies;” he added.
“I also believe that further studies into the development of more easily accessible methods of resistance testing, such as biomarker analysis of stool samples; are require. The latter would simplify treatment choice drastically and permit responsible antibiotic choices in this era of increasing antibiotic resistance.”