Helicobacter pylori

Diagnosis

  • Peptic ulcer disease (PUD)

    • Including past history of PUD, unless there is documented cure of previous H. pylori infection.
  • Uninvestigated Dyspepsia

    • WITHOUT alarming symptoms such as age > 60 with new and persistent symptoms (> 3 months); unintended weight loss; severe pain; persistent vomiting; GI bleeding; or dysphagia. If the patient presents with an alarming symptom, refer promptly to gastroenterology or general surgery/endoscopist for investigations
  • MALT lymphoma

  • Early gastric cancer

May also consider testing if:

Patients with the following conditions should generally not be tested:

  • Gastroesophageal reflux disease (GERD)

  • Lymphocytic gastritis

  • Hyperplastic gastric polyps

  • Hyperemesis gravidarum

Non-invasive testing usually preferred:

  • H. pylori stool antigen (use a dry sterile container)

  • Urea breath test (not available at all sites, contact local laboratory)

In patients undergoing endoscopy for dyspepsia, gastric biopsy urease testing can be used as well. Contact laboratory prior to submitting a sample.

To prevent false negatives, prior to testing and if clinically safe to do so: stop antibiotics and bismuth for at least 4 weeks; PPI for at least 2 weeks; and H2 receptor antagonists (H2RAs) and antacids for at least 24 hours.

DO NOT use serologic testing, as it cannot differentiate between active or prior infection

Treatment Criteria and Considerations

  • There is no universally effective therapy of H. pylori; even a threshold of 90% efficacy is difficult to achieve.

  • Culture and susceptibility testing is generally NOT available in North America.
    • We are limited to extrapolating data from other jurisdictions around the world.

  • Recent use of antibiotics increases the risk of antimicrobial resistance.

  • Antimicrobial resistance is associated with greater risk of treatment failure; particularly for clarithromycin-based and quinolone-based regimens.

  • Treatment adherence tends to decrease as the amount of daily doses increases.

  • It is essential that patients are aware of the importance of treatment adherence.

  • May consider compliance packaging (e.g. "Blister packs").

  • Smoking cessation can improve ulcer healing rates and also reduce ulcers unrelated to H. pylori

  • Pregnant and nursing women should not be treated for H. pylori

Treatment

Additional information

  • Guideline and content adapted from Vitalite Health Network H. Pylori Guideline.

  • Revised January 14, 2021

  • Fallone CA et al. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology 2016;151:51–69

  • Chey WD et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol 2017; 112:212–238; doi: 10.1038/ajg.2016.563

  • Choi IJ et al. Family History of Gastric Cancer and Helicobacter pylori Treatment. NEJM. 2020; 382:427-436. DOI: 10.1056/NEJMoa1909666

  • Blondel-Hill & Fryters. Bugs & Drugs. Accessed 01-2020

  • Hopkins ABX Guide. Accessed 01-2020

  • Deprescribing.org – PPI algorithm. Accessed 01-2020

  • Farrell B et al. Deprescribing proton pump inhibitors. Canadian Family Physician. 2017; 63 (5): 354-364

  • De Roza MA et al. Proton pump inhibitor use increases mortality and hepatic decompensation in liver cirrhosis. World J Gastroenterol. 2019 Sep 7;25(33):4933-4944. doi: 10.3748/wjg.v25.i33.4933.

  • Lin L. et al. Acid suppression therapy and its association with spontaneous bacterial peritonitis incidence: A systemic review and meta-analysis. Hepatol Res. 2019 Oct 30. doi: 10.1111/hepr.13447.

  • Wang J et al. Adverse outcomes of proton pump inhibitors in chronic liver disease: a systematic review and meta-analysis. Hepatol Int. 2020 Jan 7. doi: 10.1007/s12072-019-10010-3

  • Loo VG, Davis I, et al. Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection. Official Journal of the Association of Medical Microbiology and Infectious Disease Canada 3.2, 2018

  • The Ottawa Hospital Therapeutic Tips & Trends: H. pylori: treatment regimens & FAQs. 2018.

  • RXFiles. H. pylori testing and eradications. Accessed 09-2020.