Guideline released on treatment of Helicobacter pylori infection

Clarithromycin triple therapy should be used for first-line treatment of Helicobacter pylori infection only in patients with no history of macrolide exposure who live in areas where H. pylori resistance to clarithromycin is known to be low, according to a recent guideline.

The guideline from the American College of Gastroenterology on H. pylori treatment in North America replaces its 2007 guideline on the topic. The guideline examined the epidemiology of H. pylori, including which groups are at high risk; indications to test for and treat H. pylori infection; first-line treatment strategies; factors that predict successful eradication of H. pylori; H. pylori antimicrobial resistance; testing for treatment success; options for salvage therapy; and penicillin allergy testing.

The guideline recommends testing for H. pylori in all patients who have active peptic ulcer disease (unless a previous H. pylori cure has been documented), low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma, or history of endoscopic resection of early gastric cancer, with treatment offered to those who test positive. The guideline also recommended testing for H. pylori in patients starting chronic NSAID treatment and those with unexplained iron deficiency despite appropriate evaluation, among other groups. The guideline noted that there is insufficient evidence to support routine testing for and treatment of H. pylori infection in asymptomatic patients with a family history of gastric cancer or in patients with lymphocytic gastritis, hyperplastic gastric polyps, and hyperemesis gravidarum.

For treatment, the guideline recommends clarithromycin triple therapy with a proton-pump inhibitor (PPI), clarithromycin, and amoxicillin or metronidazole for 14 days only in regions where H. pylori clarithromycin resistance is known to be less than 15% and in patients with no previous macrolide exposure. Other recommended first-line treatment options include bismuth quadruple therapy with a PPI, bismuth, tetracycline, and a nitroimidazole for 10 to 14 days (especially in patients with previous macrolide exposure and those who are allergic to penicillin) and concomitant therapy with a PPI, clarithromycin, amoxicillin, and a nitroimidazole for 10 to 14 days.

The guideline recommended that eradication testing be done after treatment using a urea breath test, a fecal antigen test, or biopsy-based testing at least four weeks after antibiotic therapy has been completed and after PPI therapy has been withheld for one to two weeks. It also recommended that referral for allergy testing should be considered in patients with reported penicillin allergy in whom first-line therapy has failed, since most of this population can take amoxicillin-containing salvage therapy safely.

The guideline was published online on Jan. 10 by the American Journal of Gastroenterology.