Who should be treated? How to treat? How can drug resistance in the treatment of Helicobacter pylori (Hp) infection be avoided or overcome? These are the questions of most interest to clinicians dealing with Hp infections.
With more than half of the world’s population infected with H. pylori (H. pylori for short) and China having a high prevalence of Hp infection, treatment of Hp infection is a major focus in the field of Hp research.
Not all people with Hp infection need treatment, and who does? Although each country has its own set of criteria, the principles are largely the same. To date, China has issued three consensus opinions on several issues in the management of Hp infection, namely the 1999 Hainan Consensus, the 2003 Tongcheng Consensus, and the 2007 Lushan Consensus.
First, the Tongcheng consensus mentioned that “chronic gastritis with obvious abnormalities” (chronic gastritis with combined erosion, moderate-to-severe atrophy, moderate-to-severe enterosis or mild-to-severe heterogeneous hyperplasia) as an indication for Hp eradication; the 2007 Lushan consensus was modified to “chronic gastritis with gastric mucosal atrophy and erosion “.
Second, functional dyspepsia (FD) and non-ulcer dyspepsia (NUD) have been controversial in terms of definition. In the Tongcheng Consensus, Hp eradication is only recommended for “partial FD”, but the content of “partial” is not specified. The Lushan Consensus revised “partial FD” to “chronic gastritis with dyspeptic symptoms”, because the diagnosis of NUD is easier for clinicians to grasp and accept than FD.
Thirdly, the relationship between Hp eradication and the occurrence of gastroesophageal reflux disease (GERD) is also a controversial issue. The Lushan consensus has removed GERD from the indications for Hp eradication. The current view is that Hp eradication does not affect the therapeutic effect of proton pump inhibitors (PPI) in GERD patients, and Hp eradication should be performed in Hp-positive GERD patients who require long-term PPI maintenance therapy.
Fourth, the current domestic and international consensus on whether to eradicate Hp in “individuals who strongly request treatment” is: 90% of age, and the results can be obtained within 1 h. When the RUT is positive, Hp eradication therapy can be performed, but note that there is a possibility of false negative RUT. 2. gastritis, recent or ongoing application of PPI or antibiotics, there is a possibility of false negatives for many tests (except serological tests) including RUT, bacterial culture, histology, and UBT, when serological tests or multiple methods are recommended for confirmation.
PPI triple 7-day therapy is preferred
1.PPI triple 7-day therapy is still the first choice.
2.When the rate of metronidazole resistance is ≤40%, PPI + metronidazole (M) + clarithromycin (C) or amoxicillin (A) should be considered first.
3.When the rate of clarithromycin resistance ≤ 20%, PPI+C+A or PPI+C+M should be considered first.
4, RBC triple therapy (RBC + two antibiotics) can still be used as the first-line treatment plan.
5, In order to improve the Hp eradication rate and avoid secondary drug resistance, quadruple therapy can be used as the first-line treatment plan.
6.Since Hp is resistant to metronidazole and clarithromycin, while furazolidone, tetracycline and quinolones (such as levofloxacin and moxifloxacin) have low resistance rate and relatively high efficacy, thus they can also be used as the choice of initial treatment regimen.
7, at least 2 weeks before Hp eradication treatment, the drug PPI, H2-receptor antagonist (H2RA) and bismuth, which have an inhibitory effect on Hp, should not be applied, so as not to affect the efficacy.
8. Treatment method and duration: Each regimen is twice daily for 7 or 10 days (for areas with severe drug resistance, appropriate extension to 14 days can be considered, but do not exceed 14 days).
Five recommendations to avoid drug resistance
How to avoid or overcome Hp resistance to antibiotics and avoid the emergence of drug-resistant strains is one of the priorities of future therapeutic research. To avoid the emergence of drug-resistant strains of Hp, my experience is as follows.
1, choose a formal and effective treatment plan, and strictly grasp the indications for Hp eradication. Gastroenterologists and primary care physicians should work closely together and strengthen the popularization and updating of primary care physicians’ knowledge of Hp treatment.
2, Combination of drugs, avoid the eradication of Hp with a single antibiotic.
3. An effective treatment plan should be given at the first treatment. In order to improve the Hp eradication rate, quadruple therapy can also be used for the first treatment to minimize retreatment, so as to avoid secondary resistance of Hp to antibiotics due to repeated treatment.
4, Hp resistance rate testing should be done in conditional areas, when the metronidazole resistance rate ≥ 40%, clarithromycin resistance rate ≥ 15% ~ 20%, then it is not appropriate to use metronidazole or clarithromycin.
5. For those who have failed several times in consecutive treatment, it is recommended that an interval of 3~6 months be allowed for Hp to recover its activity before Hp eradication treatment.