Helicobacter pylori

Common chronic bacterial infection of the gastric epithelium associated with peptic ulcer disease, chronic gastritis and stomach cancers (adenocarcinoma and MALT)

Testing

Initial testing is done by Urea Breath Test or Stool Antigen Test

Indications supported by strong evidence:

  • MALT lymphoma

  • Active peptic ulcer disease or previous treatment without documented cure

  • Early gastric cancer

Controversial indications supported by limited evidence:

  • Dyspepsia in patients <50 y/o with no alarm features (persistant vomiting, unexplained bleeding or anemia, abdominal mass, unexpected weight loss, dysphagia)

  • Prior chronic treatment with NSAIDs or low-dose ASA

  • Unexplained iron deficiency

  • Immune thrombocytopenia

  • Those with GERD-predominant symptoms

  • Asymptomatic individuals with family history

  • Pregnant women with hyperemesis gravidarum

  • Those with gastric polyps

  • New onset persistent dyspepsia in patients > 50 y/o

  • No or limited response to acid suppression therapy

  • Dyspepsia with alarm features (persistant vomiting, unexplained bleeding or anemia, abdominal mass, unexpected weight loss, dysphagia)

  • Failure of two H pylori treatments warrants endoscopy, biopsy and culture and sensitivity

Test of cure recommendations vary and some resources recommend testing for cure in all patients.

Generally, test of cure should be performed in patients with:

  • persistent dyspepsia

  • gastric or duodenal ulcers

  • gastric cancer

  • questionable compliance or having taken second line therapy

Types of Tests for H. pylori

  • Non-invasive test used for diagnosis and test of cure

  • Takes 1-2 days for results

  • PPIs and bismuth need to be stopped 2 and 4 weeks prior respectively, but antibiotics do not interfere

  • Sensitivity 94%; specificity 97%

  • Non-invasive test used for diagnosis and test of cure

  • Takes 15-20 mins for results

  • PPIs, bismuth and antibiotics interfere with test and need to be stopped 2-4 weeks prior

  • Sensitivity 88-95%; specificity 95-100%

  • Infrequently used

  • Cannot distinguish active vs. prior infection

  • Biopsy Urease test: most common; results in 1 hr; sensitivity and specificity similar to UBT

  • Histology: slow turn around time; used in conjunction with gastric cancer work-up

  • Culture and Sensitivity: done in multiple treatment failures; low sensitivity

Stop PPIs 2 weeks prior and bismuth 4 weeks prior to all testing except serology

UBT and Stool Antigen Test are equally useful; choice between the two is based on clinician preference

As H. pylori is difficult to grow, culture and sensitivity as well as antibiogram information are not routinely available;

endoscopic culture can be performed in cases of multiple treatment failures

All patients who test positive should be treated

Duration of Treatment

14 days for all regimens

Empiric First-line Quadruple Therapies

AND

AND

WITH

In hospital:
Pantoprazole 40mg IV/PO BID or
Esomeprazole 20mg NG BID

Outpatient:
Rabeprazole 20mg PO BID (most cost effective), or
Pantoprazole 40mg PO BID, or
Omeprazole 20mg PO BID, or
Lansoprazole 30mg PO BID, or
Esomeprazole 20mg PO BID

Special Authority is required for all PPIs

OR

AND

AND

Bismuth Subsalicylate (Pepto-bismol) TWO 262mg caplets PO QID

WITH

In hospital:
Pantoprazole 40mg IV/PO BID or
Esomeprazole 20mg NG BID

Outpatient:
Rabeprazole 20mg PO BID (most cost effective), or
Pantoprazole 40mg PO BID, or
Omeprazole 20mg PO BID, or
Lansoprazole 30mg PO BID, or
Esomeprazole 20mg PO BID

Special Authority is required for all PPIs

Third-line Therapy for Failures of Above

AND

Levofloxacin 500mg PO daily

AND

Bismuth Subsalicylate (Pepto-bismol) TWO 262mg caplets PO QID

WITH

In hospital:
Pantoprazole 40mg IV/PO BID or
Esomeprazole 20mg NG BID

Outpatient:
Rabeprazole 20mg PO BID (most cost effective), or
Pantoprazole 40mg PO BID, or
Omeprazole 20mg PO BID, or
Lansoprazole 30mg PO BID, or
Esomeprazole 20mg PO BID

Special Authority is required for all PPIs

In hospitalized patients with perforated viscus, begin treatment once source control is achieved

Local sensitivities to other antimicrobials like ceftriaxone or piperacillin/tazobactam are not known; do not substitute/omit any drugs from the quadruple therapy in hospitalized patients on these antibiotics

Compliance is essential for optimizing eradication and preventing resistance

Triple therapies like HP Pack are no longer recommended

Treatment failures occur in 15-20% of all patients:

  • 1st failure should be re-treated with a different quadruple therapy

  • 2nd failure should be treated with second-line therapy

The following substitutions are NOT recommended:

  • azithromycin for clarithromycin due to poorer tolerably, slightly higher cost and a very long half-life

  • doxycycline for tetracycline due to sub-optimal H. pylori activity

Note QID vs. BID dosing for metronidazole in the two regimens

Special Authority is required for all PPIs and levofloxacin

Re-acquisition of H. pylori following cure is rare (~1%)

Microbiology

Helicobacter pylori