ACG updates guideline on H. pylori treatment
Among other recommendations, the American College of Gastroenterology (ACG) said that 14 days of bismuth quadruple therapy is the preferred regimen for treatment-naive patients with Helicobacter pylori infection when antibiotic susceptibility is unknown.
The American College of Gastroenterology (ACG) recently released an updated clinical guideline on treatment of Helicobacter pylori.
The goal of the guideline, which was last updated in 2017, is to inform evidence-based management of patients with H. pylori infection in North America. The ACG noted that its recommendations have changed substantially since 2017 due to increased antibiotic resistance, including to clarithromycin and levofloxacin, and new research on novel antibiotics and potassium-competitive acid blockers (PCABs). (For more on the latter, see the Keeping tabs section in this issue.) The guideline was published in the September American Journal of Gastroenterology.
For treatment-naive patients with H. pylori infection, bismuth quadruple therapy for 14 days is the preferred regimen when antibiotic susceptibility is unknown (strong recommendation, moderate-quality evidence), the guideline said. This therapy typically includes a bismuth salt (e.g., bismuth subcitrate or subsalicylate), a nitroimidazole (usually metronidazole but possibly tinidazole), tetracycline (preferred over doxycycline), and a proton-pump inhibitor (PPI), according to the guideline. Other suggested first-line treatment options are rifabutin triple therapy (conditional recommendation; low-quality evidence) or dual therapy with a PCAB and amoxicillin (conditional recommendation; moderate-quality evidence) in patients without penicillin allergy.
Regimens containing clarithromycin and levofloxacin should be avoided in settings without demonstrated macrolide and quinolone susceptibility, the guideline said. In treatment-naive patients with unknown clarithromycin susceptibility, PCAB-clarithromycin triple therapy is suggested over triple therapy with PPIs and clarithromycin, the guideline said (conditional recommendation; moderate-quality evidence). Concomitant therapy, defined as a PPI, clarithromycin, amoxicillin, and metronidazole twice daily for five to 14 days, is not suggested over bismuth quadruple therapy in treatment-naive patients, the guideline said (conditional recommendation; low-quality evidence).
Optimized bismuth quadruple therapy is suggested in treatment-experienced patients with persistent H. pylori infection who have not previously received it, the guideline said (conditional recommendation; very low-quality evidence), as well as in those who have previously received PPI-clarithromycin triple therapy (conditional recommendation; very low-quality evidence). This regimen is defined as bismuth, 300 mg at least four times daily; metronidazole, 1.5 to 2 g daily in three or four doses; tetracycline, 500 mg four times daily; and twice-daily standard-dose PPI for 10 to preferably 14 days.
In treatment-experienced patients with persistent infection who have received bismuth quadruple therapy, rifabutin triple therapy is suggested, the guideline said (conditional recommendation; low-quality evidence). Levofloxacin triple therapy is suggested in treatment-experienced patients with known levofloxacin-sensitive strains of H. pylori, as well as when optimized bismuth quadruple or rifabutin triple therapies have already been used or are not available (conditional recommendation; low-quality evidence).
There is not enough evidence from North America to recommend high-dose PPI or PCAB dual therapy in treatment-experienced patients with persistent infection, the guideline said (no recommendation; evidence gap). The guideline also noted that there is insufficient evidence to suggest that probiotic therapy improves the efficacy or tolerability of H. pylori eradication therapy (conditional recommendation; low-quality evidence).