Helicobacter pylori Infection

Background

• Helicobacter pylori is a spiral-shaped gram-negative bacterium transmitted through the fecal-oral route that may be present in the gastrointestinal tract of more than half of people worldwide.
• H. pylori infection is associated with upper gastrointestinal diseases such as chronic gastritis, peptic ulcer disease, and gastric malignancy.
• Adults and children infected with H. pylori may be asymptomatic or present with symptoms such as dyspepsia, epigastric abdominal pain, or signs of gastrointestinal bleeding.
• Smoking and chronic nonsteroidal anti-inflammatory drug (NSAID) use may significantly increase the risk of peptic ulcer disease in those infected with H. pylori.

Evaluation

• Test for Helicobacter pylori infection in patients with a current or prior documented peptic ulcer or gastric malignancy (Strong recommendation), and consider testing in patients with uninvestigated dyspepsia, patients on long-term low-dose aspirin, patients with unexplained iron deficiency anemia and patients with idiopathic thrombocytopenic purpura (ITP) (Weak recommendation).
• Noninvasive tests include:
  • urea breath test:
    • useful before and after eradication therapy
    • may be the most accurate test for patients with upper gastrointestinal bleeding
  • stool antigen test
  • antibody testing (including blood and urine tests) - only useful before eradication therapy, as the test can remain positive after eradication of bacteria.
• Invasive testing via endoscopy may be used for diagnosis or to evaluate for eradication after antibiotic therapy.
• For patients undergoing endoscopy to evaluate dyspepsia, perform histological testing (Strong recommendation). Other options for testing may include rapid urease testing, culture and sensitivity or molecular testing, such as polymerase chain reaction.
• Any test for active infection of Helicobacter pylori infection (including, urea breath test, stool antigen test, histologic biopsy, rapid urease testing, culture) may result in false-negative results if the patient is on bismuths, antibiotics, proton pump inhibitors, and/or high-dose histamine-2 receptor (H2) blockers during testing.

Management

• Offer treatment to all patients who test positive for active infection with Helicobacter pylori (Strong recommendation).
• Eradication regimens include:
  • clarithromycin triple therapy for 14 days with a PPI orally twice daily, clarithromycin 500 mg orally twice daily, and either amoxicillin 1,000 mg orally twice daily OR metronidazole 500 mg orally 3 times daily; recommended option in regions where clarithromycin resistance known to be < 15%, which rules out use in much of North America; and in patients without any previous macrolide exposure (Weak recommendation)
  • bismuth quadruple therapy for 10-14 days with PPI orally twice daily, plus bismuth subsalicylate 300 mg, metronidazole 250 mg, AND tetracycline 500 mg, all orally 4 times daily (Strong recommendation)
  • concomitant therapy for 10-14 days, with a PPI, clarithromycin 500 mg, amoxicillin 1,000 mg, AND metronidazole 500 mg, all orally twice daily (Strong recommendation)
• Probiotics during H. pylori eradication therapy may reduce the side effects of treatment and potentially increase eradication rates, however, it is not currently possible to make a recommendation regarding a specific strain, duration or dose of probiotic based upon the available data.
• Confirm eradication > 4 weeks after completion of the antibiotic therapy (Strong recommendation).
• Eradication rates are typically about 70%-85% with each course of therapy, but vary depending on local antibiotic resistance patterns. Smoking is associated with higher failure rates.
• For patients with persistent H. pylori infection, choose a salvage therapy option that does not include antibiotics taken by the patient for H. pylori infection in the past (Strong recommendation), and consider local antimicrobial resistance data (Weak recommendation).