H. pylori remains highly prevalent in most parts of the world with guidelines ensuring regimens based on the latest epidemiological and clinical evidence. The three most recent guidelines on H. pylorimanagement include the Toronto Consensus statement, the Maastricht V/Florence Consensus report and the American College of Gastroenterology guidelines. A September 2017 review integrated findings based on similarities in global recommendations to produce an overall therapeutic consensus. They found a common theme of increasing antibiotic resistance, associated with reduced efficacy of standard eradication/treatment regimens. The authors stressed that H. pylori needs to be regarded as an infectious disease and that treatment regimens need to be based on regional antibacterial profiles, resistance patterns and available health care systems.
In general the first approach to therapy should incorporate a quadruple regimen, utilising bismuth or an antibiotic base. Duration should be at least 14 days, as shorter durations of therapy have been associated with lower eradication rates. In a change from earlier recommendations, the newer guidelines all emphasised that clarithromycin triple therapy should not be used unless the local clarithromycin resistance rate is less than 15%. The American College of Gastroenterology also provided conditional recommendations for levofloxacin triple therapy and fluoroquinolone sequential therapy as first-line treatment options.
When treating a patient who has failed first–line therapy, the second line regimen should take the earlier failed regimen into account. The most common recommendation in these patients is to use quadruple bismuth or levofloxacin-based therapy. If a patient has failed numerous therapies it is important to perform sensitivity analysis on their H. pylori and use the results to create individualised treatment. The authors emphasised that H. pylori infection poses a public health risk and is a chronic condition that requires effective eradication.
Curr Treat Options Gastroenterol. 2017 Sep 21. doi: 10.1007/s11938-017-0157-8. [Epub ahead of print]