One discussion this week involved the management of patients with helicobacter pylori infection.

Reference: DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. T114484, Helicobacter pylori infection; [updated 2018 Dec 04, cited 2019 Apr 05]. Emory login required. [NOTE: direct link is not functional. Go to DynaMed Plus main page and search “helicobacter pylori infection” to access full content.]

Summary: Management overview (DynaMed Plus, 2018)

• offer treatment to all patients who test positive for active infection with Helicobacter pylori (ACG Strong recommendation)⁽¹⁾; the clinical efficacy of H. pylori eradication varies among associated conditions
  • peptic ulcer disease
    • in patients with H. pylori-positive duodenal ulcers, H. pylori eradication therapy (alone or in addition to ulcer-healing drugs) may increase ulcer healing, and eradication therapy alone may reduce ulcer recurrence (level 3 [lacking direct] evidence)
    • in patients with H. pylori-positive gastric ulcers, addition of H. pylori eradication therapy to ulcer-healing drugs may not improve ulcer healing but H. pylori eradication therapy alone may reduce ulcer recurrence (level 3 [lacking direct] evidence)
    • peptic ulcer bleeding
      • H. pylori eradication therapy appears more effective than short-term antisecretory therapy or long-term ranitidine in preventing recurrent peptic ulcer bleeding in patients not taking nonsteroidal anti-inflammatory drugs (NSAIDs) (level 2 [mid-level] evidence)
      • H. pylori eradication therapy appears less effective than daily proton pump inhibitor (PPI) for preventing recurrent peptic ulcer bleeding in patients who continue long-term NSAIDs (level 2 [mid-level] evidence)
  • precancerous gastric lesions – H. pylori eradication may reduce progression of lesions (level 3 [lacking direct] evidence)
  • iron deficiency anemia – eradicating H. pylori may improve response to oral iron therapy
    • > 50% of patients with unexplained refractory iron deficiency anemia reported to have active H. pylori infection ( Blood 2014 Jan 16;123(3):326 full-text)
    • addition of H. pylori eradication appears to increase the efficacy of oral iron supplementation in patients with iron deficiency anemia and H. pylori infection (level 3 [lacking direct] evidence)
  • nonulcer dyspepsia – H. pylori eradication improves but does not eliminate symptoms (level 1 [likely reliable] evidence)
  • chronic gastritis – H. pylori eradication may decrease histologic evidence of gastritis in multiple clinical settings (level 3 [lacking direct] evidence), but may not be associated with improved symptoms in children (level 2 [mid-level] evidence)
  • long-term PPI use – H. pylori eradication reduces healthcare use and may reduce dyspepsia symptoms but not reflux symptoms (level 1 [likely reliable] evidence)
  • long-term NSAID use – H. pylori eradication prevents ulcers and ulcer complications in patients starting NSAIDs (level 1 [likely reliable] evidence) but may be less effective than long-term PPI use (level 2 [mid-level] evidence)
  • immune thrombocytopenia – H. pylori eradication improves platelet count (level 2 [mid-level] evidence)
  • gastroesophageal reflux disease (GERD) – H. pylori eradication does not clearly cause, improve, or worsen GERD symptoms (level 2 [mid-level] evidence)
  • asymptomatic patients – H. pylori eradication may prevent future dyspepsia (level 2 [mid-level] evidence), but low overall risk (< 15%) may not warrant such therapy
• when choosing therapy, consider all of following⁽¹⁾
  • patient’s history of penicillin allergy, and history of macrolide exposure
  • patient’s ability to adhere to a multidrug regimen with potential adverse effects
  • sensitivity of regional H. pylori strain to the combination of antibiotics administered (H. pylori clarithromycin resistance is > 15% in many areas of North America); see Antimicrobial resistance considerations in Recommendations section for details

Additional Reading: Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobactor pylori infection. American Journal of Gastroenterology. 2017 Feb;112(2):212-239. doi: 10.1038/ajg.2016.563.