A review has summarised three recently published guidelines on the management of Helicobacter pylori: the Toronto consensus statement, the Maastricht V/Florence consensus report, and the American College of Gastroenterology guidelines on H pylori.
Study authors David J Bjorkman and Matthew Steenblik, from the University of Utah School of Medicine, Salt Lake City, Utah, compared and contrasted the recommendations and offered a best practice approach for integrating the 3 guidelines.
With regards to treatment approach, the authors recommend antibiotic selection be based on local and individual resistance patterns, as the efficacy of previously established treatment regimens for H pylori have diminished over time with increasing antibiotic resistance.
A 14-day course of bismuth- or antibiotic-based quadruple therapy should be considered first-line treatment, while triple therapy with clarithromycin should not be used unless the local resistance rate is <15%. Second-line therapy, such as quadruple bismuth-based therapy or levofloxacin-based therapy, can be considered when first-line therapy has failed. In addition, antibiotic resistance testing is recommended after multiple treatment failures.
“Additional efforts are needed to define local antibiotic resistance to allow susceptibility-based treatment. In the meantime, 14-day quadruple therapy with bismuth or concomitant antibiotics is recommended as an empiric first-line treatment approach,” conclude the authors.
Purpose of review: Three guidelines on Helicobacter pylori have been published recently with recommendations that differ from past guidelines. In this review, we summarize the Toronto consensus statement, the Maastricht V/Florence consensus report and the American College of Gastroenterology guidelines on H. pylori, comparing and contrasting the recommendations. We also provide a proposed approach integrating the information from all three guidelines.
Findings: Increasing antibiotic resistance has decreased the effectiveness of past treatment regimens for H. pylori. The recommended treatment approach should be based on local and individual antibiotic resistance patterns. Empiric first-line therapy should be a 14-day course of bismuth- or antibiotic-based quadruple therapy. Clarithromycin triple therapy is not recommended unless the local clarithromycin resistance rate is less than 15%. Second-line therapy should be influenced by the failed first-line therapy. Quadruple bismuth-based therapy or levofloxacin-based therapy are suggested regimens. Testing for antibiotic resistance is recommended after multiple failed treatments.
Summary: Therapy of H. pylori should be based on the knowledge of local antibiotic resistance patterns. Unfortunately, these are often not available. Additional efforts are needed to define local antibiotic resistance to allow susceptibility-based treatment. In the meantime, 14-day quadruple therapy with bismuth or concomitant antibiotics is the recommended as an empiric first-line treatment approach.
David J Bjorkman, Matthew Steenblik