gastrointestinal disorders
Helicobacter pylori Infection
Treatment ofH. pyloriInfection
Antibiotics (various regimens) plus a proton pump inhibitor For confirmation of cure,ureabreath test, stool antigen assay, or upper endoscopy (See also the American College of Gastroenterology’s [ACG] 2017 guidelinesTreatment of Helicobacter pylori Infectionand the European 2022 guidelinesManagement of Helicobacter pylori infection: The Maastricht VI/Florence consensus report.) Patients with complications (eg, ulcer, cancer) should have the organism eradicated. Eradication ofH. pylorican even cure some cases of MALT lymphoma (but not other infection-related cancers). Treatment of asymptomatic infection has been controversial, but the recognition of the role ofH. pyloriin cancer has led to a recommendation for treatment. Vaccines, both preventive and therapeutic (ie, as an adjunct to treatment of infected patients), are under development. eradication requires multidrug therapy, typically antibiotics plus acid suppressants ( Treatment references ). Proton pump inhibitors suppress resistance rate is > 15% and is recommended in both the European guidelines ( Treatment references ) and in the ACG guidelines ( A proton pump inhibitor (lansoprazole30 mg 2 times a day,omeprazole20 mg 2 times a day,pantoprazole40 mg 2 times a day,rabeprazole20 mg 2 times a day, oresomeprazole40 mg once a day) Bismuth subsalicylate524 mg 4 times a day Metronidazole250 mg 4 times a day Tetracycline500 mg 4 times a day resistance is known to be < 15% and in patients with no previous history of macrolide exposure, triple therapy with the following oral medications for 14 days remains an initial treatment option ( Treatment references , A proton pump inhibitor (lansoprazole30 mg 2 times a day,omeprazole20 mg 2 times a day,pantoprazole40 mg 2 times a day,rabeprazole20 mg 2 times a day, oresomeprazole40 mg once a day) Amoxicillin1 g 2 times a dayormetronidazole250 mg 4 times a day Clarithromycin500 mg 2 times a day , and a fluoroquinolone ( Treatment references ). There is a high prevalence of fluoroquinolone resistance in the United States, so this strategy may not be applicable there. Triple therapy with low-dose not be used if quadruple therapy fails ( Treatment references ). The European guidelines suggest double or triple therapy with a potassium-competitive acid inhibitor may be superior or noninferior to standard triple therapy ( Treatment references , Infected patients with duodenal or gastric ulcer require continuation of the acid suppression for at least 4 weeks. Eradication may be confirmed by aureabreath test, stool antigen test, or upper endoscopy done ≥ 4 weeks after completion of therapy. Confirmation of eradication is reasonable in all treated patients but is mandatory in patients who have serious manifestations ofH. pyloriinfection (eg, bleeding ulcer). Recurrent bleeding ulcer is likely if the infection is not eradicated. triple therapy, or an alternate bismuth-containing therapy ( Treatment references ). 1.Yang JC, Lin CJ, Wang HL, et al: High-dose dual therapy is superior to standard first-line or rescue therapy forHelicobacter pyloriinfection.Clin Gastroenterol Hepatol13(5):895–905.e5, 2015. doi: 10.1016/j.cgh.2014.10.036 2.Malfertheiner P, Megraud F, Rokkas T, et al: Management ofHelicobacter pyloriinfection: The Maastricht VI/Florence consensus report.Gutgutjnl-2022-327745, 2022. doi: 10.1136/gutjnl-2022-327745 3.Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG clinical guideline: Treatment ofHelicobacter pyloriinfection.Am J Gastroenterol112(2):212–239, 2017. doi: 10.1038/ajg.2016.563.Clarification and additional information.Am J Gastroenterol113(7):1102, 2018. doi: 10.1038/s41395-018-0132-6 4.Fallone CA, Chiba N, van Zanten SV, et al: The Toronto consensus for the treatment ofHelicobacter pyloriinfection in adults.Gastroenterology151(1):51–69, 2016. doi: 10.1053/j.gastro.2016.04.006 5.Graham DY, Canaan Y, Maher J, et al:Rifabutin-based triple therapy (RHB-105) forHelicobacter pylorieradication: A double-blind, randomized, controlled trial.Ann Intern Med172(12):795–802, 2020. doi: 10.7326/M19-3734 6.Fiorini G, Zullo A, Vakil N, et al:Rifabutintriple therapy is effective in patients with multidrug-resistant strains ofHelicobacter pylori.J Clin Gastroenterol52(2):137–140, 2018. doi: 10.1097/MCG.0000000000000540 7.Chey WD, Mégraud F, Laine L, et al:Vonoprazantriple and dual therapy forHelicobacter pyloriinfection in the United States and Europe: Randomized clinical trial.Gastroenterology163(3):608–619, 2022. doi: 10.1053/j.gastro.2022.05.055 8.Shah SC, Iyer PG, Moss SF: AGA clinical practice update on the management of refractoryHelicobacter pyloriinfection: Expert review.Gastroenterology160(5):1831–1841, 2021. doi: 10.1053/j.gastro.2020.11.059 