Helicobacter pylori diagnosis and therapy in the era of antimicrobial stewardship

Abstract

The diagnosis and therapy of Helicobacter pylori infection have undergone major changes based on the use the principles of antimicrobial stewardship and increased availability of susceptibility profiling. H. pylori gastritis now recognized as an infectious disease, as such there is no placebo response allowing outcome to be assessed in relation to the theoretically obtainable cure rate of 100%. The recent recognition of H. pylori as an infectious disease has changed the focus to therapies optimized to reliably achieve high cure rates. Increasing antimicrobial resistance has also led to restriction of clarithromycin, levofloxacin, or metronidazole to susceptibility-based therapies. Covid-19 resulted in the almost universal availability of polymerase chain reaction testing in hospitals which can be repurposed to utilize readily available kits to provide rapid and inexpensive detection of clarithromycin resistance. In the United States, major diagnostic laboratories now offer H. pylori culture and susceptibility testing and American Molecular Laboratories offers next-generation sequencing susceptibility profiling of gastric biopsies or stools for the six commonly used antibiotics without need for endoscopy. Current treatment recommendations include (a) only use therapies that are reliably highly effective locally, (b) always perform a test-of-cure, and (c) use that data to confirm local effectiveness and share the results to inform the community regarding which therapies are effective and which are not. Empiric therapy should be restricted to those proven highly effective locally. The most common choices are 14-day bismuth quadruple therapy and rifabutin triple therapy. Prior guidelines and treatment recommendations should only be used if proven locally highly effective.

Optimization of vonoprazan‐amoxicillin dual therapy for eradicating Helicobacter pyloriinfection in China: A prospective, randomized clinical pilot study

“…and amoxicillin of 1500 mg/day. 8 The success of amoxicillin-VPZ dual therapy is thought to largely depend on the ability of VPZ to maintain the gastric pH high enough for H. pylori to remain in the state of active replication where the organism becomes susceptible to amoxicillin. 5 Japan government restrictions limit the duration of therapy to 7 days and overall, the efficacy of 7-day Vonoprazan-amoxicillin (VA) dual therapy has failed to achieve >95% eradication rate when given with 1500 mg of amoxicillin.…”

“…In Japan, the combination of vonoprazan (VPZ), a potassium‐competitive acid blocker, and amoxicillin as a dual therapy has been shown to provide cure rates at near 90% using daily doses of VPZ 20 mg b.i.d. and amoxicillin of 1500 mg/day 8 . The success of amoxicillin‐VPZ dual therapy is thought to largely depend on the ability of VPZ to maintain the gastric pH high enough for H. pylori to remain in the state of active replication where the organism becomes susceptible to amoxicillin 5 …”

Efficacy and safety of low‐dose rifabutin‐based 7‐day triple therapy as a third‐ or later‐lineHelicobacter pylorieradication regimen

“…Therefore, the influence of the CYP2C19 genotype status on gastric acid suppression by VPZ could be small 47 . In Asia, where CYP2C19 rapid metabolizers are uncommon and gastric acid secretion is generally low due to corpus gastritis, have shown that the combination high dose PPI–amoxicillin can produce higher cure rates than it in western populations 48 . Subsequent studies using a factorial design (i.e., with and without RFB) will be needed to address the question whether or what proportion of the observed outcome was related to the presence of RFB.…”

Current guidelines for Helicobacter pylori treatment in East Asia 2022: Differences among China, Japan, and South Korea

“…Macrolides have been widely used to treat other infectious diseases. Accordingly, the number of CAM-resistant H. pylori strains has increased rapidly in many countries over the past decade[ 14 ]. In East Asia, CAM resistance of H. pylori has increased by > 15%.…”

“…Tailored H. pylori eradication shows promise for achieving more successful outcomes before treatment, compared to conventional therapies[ 58 ]. Antimicrobial susceptibility testing using a culture method has been recommended for effective first-line H. pylori eradication in regions with a high rate of antibiotic resistance[ 14 ]. However, susceptibility-guided therapy is time-consuming and requires specific expertise in clinical practice[ 59 ].…”