Spotlight on Helicobacter pylori treatment

A review found that susceptibility-guided therapy may be the superior first-line treatment for H. pylori infection in areas with high antibiotic resistance, while a study of trial participants with 26.5 years of follow-up showed that H. pylori eradication may provide long-term protection against gastric cancer.

Two studies published this past month focused on treatments for patients with Helicobacter pylori infection and the effect of eradication.

First, a systematic review and meta-analysis found that susceptibility-guided therapy showed higher efficacy and similar safety to bismuth-containing quadruple therapy as first-line treatment for H. pylori infection in areas with high antibiotic resistance. In five studies that enrolled 2,110 patients with H. pylori infection, the pooled eradication rates of susceptibility-guided therapy and bismuth-containing quadruple therapy were 86% versus 78% (P<0.05) and 92% versus 86% (P>0.05) in intention-to-treat and per-protocol analyses, respectively, according to results published March 24 by Frontiers in Medicine. Susceptibility-guided therapy showed superior efficacy in a subgroup of cultures with the susceptibility test (pooled risk ratio, 1.14; P<0.05). The pooled side effect rate was 20% in susceptibility-guided therapy and 22% in bismuth-containing quadruple therapy (P>0.05), and adherence rates to the regimens were 95% and 92%, respectively.

The included studies were conducted in areas with a high resistance rate to antibiotics in China and Korea, which may limit generalizability, the authors noted. They added that the sample size of the included studies was limited, especially in a subgroup analysis. “The decision-making of first-line regimens for H. pylori infection should depend on the availability and cost-effectiveness of susceptibility tests and bismuth in local areas,” they concluded.

The second study, published March 28 by Gastroenterology, found that eradication of H. pylori may provide long-term protection against gastric cancer in high-risk populations. Researchers assessed participants in a randomized controlled trial conducted in a high-risk area in southern China in July 1995, with follow-up through December 2020. Overall, 1,630 individuals with asymptomatic H. pylori infection were randomly assigned to receive standard triple therapy for H. pylori eradication (n=817) or placebo (n=813). The primary outcome was incidence of gastric cancer. During 26.5 years of follow-up, 21 participants (2.57%) in the treatment arm and 35 (4.31%) in the placebo arm were diagnosed with gastric cancer. Those who were treated had a lower incidence of gastric cancer (hazard ratio [HR], 0.57; 95% CI, 0.33 to 0.98), and more obvious risk reduction was seen in those without premalignant gastric lesions (HR, 0.37; 95% CI, 0.15 to 0.95) and in those without dyspepsia symptoms at baseline (HR, 0.44; 95% CI, 0.21 to 0.94). Compared to 32 cases of gastric cancer in 527 participants with persistent infection in the placebo group, there were 16 cases in 625 participants with successful eradication in the treatment group (HR, 0.46; 95% CI, 0.26 to 0.83).

Detailed information from medical records of 17 of 56 (30%) gastric cancer cases was not available due to the low coverage of electronic medical records in the early study period, among other limitations, the authors noted. “In conclusion, our study provides strong evidence that H. pylori eradication therapy significantly reduces the risk of gastric cancer development, which might be confined to the subgroup without precancerous gastric lesions at baseline,” they wrote. “These findings highlight the need of prompt treatment for carriers of H pylori infection in high-risk populations, especially among those without advanced gastric lesions.”