The American Journal of Gastroenterology has published a new guideline on the treatment of Helicobacter pylori (H. pylori) infection.
The guideline’s corresponding author is William D. Chey, MD, chief of the Division of Gastroenterology and Hepatology at Michigan.
H. pylori is a bacterium that infects more than half of the world’s people, although most are asymptomatic.
It can cause dyspepsia, stomach ulcers and stomach cancer.
This latest clinical practice guideline notes that its prevalence is declining in North America, but still infects 30-40% of the population.
An earlier guideline was published in 2017. This maintained the recommendation of proton pump inhibitor-clarithromycin triple therapy as the primary treatment option.
In the new guideline, bismuth quadruple therapy is the main recommendation for treatment-naïve patients.
That treatment usually includes a PPI, tetracycline, bismuth and a nitroimidazole for 14 days.
“We already advised healthcare providers in 2017 to move away from PPI triple therapy due to the increasing problems with chlormycetin resistance in H. pylori tribes in the United States,” Chey said.
“Despite that recommendation, triple PPI therapy still dominates first-line therapy prescriptions H. pylori patients in the United States. In this latest version of the guidance, we are very clear when we say that in almost all circumstances you should not prescribe triple PPI therapy, and should instead use bismuth quadruple therapy or one of the other suggested treatment options.
The guideline provides a total of twelve treatment suggestions for patients in various situations.
The number two recommendation for treatment-naïve patients – after quadruple bismuth therapy – is triple therapy with rifabutin (a PPI, rifabutin and amoxicillin).
A third option consists of a new, very powerful drug that blocks stomach acid production, called vonoprazan, combined with the antibiotic amoxicillin.
In addition to the move away from PPI triple therapy, another change from the 2017 guideline is the discussion of increasingly available molecular tests for antibiotic sensitivity.
“Molecular testing really opens the door to the possibility of more liberally using antibiotic susceptibility testing as a mechanism to tailor therapy to the antibiotics needed.” H. pylori or a person infected with it H. pylori sensitive to,” Chey said.
The guideline also outlines future research priorities, such as identifying which individuals would benefit most H. pylori testing to prevent stomach cancer and evaluating newly FDA-approved regimens for persistent infections.
Additional authors: Colin W. Howden, MD, Steven F. Moss, MD, Douglas R. Morgan, MD, MPH, Katarina B. Greer, MD, MS, Shilpa Grover, MD, MPH, Shailja C. Shah, MD, MPH
