... AND HOW TO TREAT IT
H pylori infection is associated with an increased risk for noncardiac gastric adenocarcinoma, but a decreased risk for cardiac gastric adenocarcinoma and esophageal adenocarcinoma.35,36 Thus, the potential to reduce the risk for gastric cancer is not considered an indication for H pylori treatment. The possibility of improving dyspepsia symptoms is a reason to treat H pylori infection, although eradicating it does not always do so.
In a 2006 Cochrane Review, treating H pylori had a small but statistically significant benefit for patients with FD (NNT = 14).37 A 2011 study on the effects of H pylori eradication on symptoms and quality of life in primary care patients with FD revealed a 12.5% improvement in quality of life and a 10.6% improvement in symptoms.38
The triple-therapy regimen (a PPI + amoxicillin + clarithromycin) is the most common firstline H pylori treatment in the US and a good initial choice in regions in which clarithromycin resistance is low (see Table 2).39-44 The standard duration is seven days.
A 2013 Cochrane Review showed that a longer duration (14 days) increased the rate of eradication (82% vs 73%), but this remains controversial.39 The addition of bismuth subsalicylate to the triple-therapy regimen has been shown to increase the eradication rate of H pylori by approximately 10%.45 Adding probiotics (saccharomyces or lactobacillus) appears to increase eradication rates, as well.40
Sequential therapy consists of a five-day course of treatment in which a PPI and amoxicillin are taken twice a day, followed by another five-day course of a PPI, clarithromycin, and metronidazole. A recent meta-analysis of sequential therapy showed that it is superior to seven-day triple therapy but equivalent to 14-day triple therapy.40
LOAD (levofloxacin, omeprazole, nitazoxanide, and doxycycline) therapy for seven to 10 days can be used in place of triple therapy in areas of high resistance or for persistent H pylori. In one study, the H pylori eradication rate for a seven-day course of LOAD therapy—levofloxacin and doxycycline taken once a day, omeprazole before breakfast, and nitazoxanide twice daily—was 90% (vs 73.3% for a seven-day course of triple therapy).41
Quadruple therapy has two variations: bismuth-based and nonbismuth (concomitant) therapy. The latter uses the base triple therapy and adds either metronidazole or tinidazole for seven to 14 days. In a multicenter randomized trial, this concomitant therapy was found to have similar efficacy to sequential therapy.42
Bismuth-based quad therapy includes a PPI, bismuth, metronidazole, and tetracycline. A meta-analysis found it to have a higher rate of eradication than triple therapy for patients with antibiotic resistance.43,44
For persistent H pylori, a PPI, levofloxacin, and amoxicillin for 10 days has been shown to be more effective and better tolerated than quadruple therapy.12
Confirmation is indicated when symptoms persist
If dyspepsia symptoms persist after H pylori treatment, it is reasonable to retest to confirm that the infection has in fact been eradicated. Confirmation is also indicated if the patient has an H pylori-associated ulcer or a prior history of gastric cancer.
Retesting should be performed at least four to six weeks after treatment is completed. If H pylori has not been eradicated, you can try another regimen. If retesting confirms eradication and symptoms persist, EGD with biopsy is indicated. Although EGD typically has a very low yield, even for patients with red flags, this invasive test often provides reassurance and increased satisfaction for patients with persistent symptoms.46
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