New guidelines on the management of Helicobacter pylori say infection controls are being challenged by rising antibiotic resistance around the world.

The sixth edition of global Maastricht/Florence Consensus Report, published in Gut (link), recognises H. pylori gastritis as an infectious disease that should prompt treatment for all infected patients.

The first update since 2017 also confirms agreement that H. pylori infection is the primary aetiological factor for gastric adenocarcinoma including proximal gastric cancer and played a role in in a subset of adenocarcinoma of the Gastro-oesophageal Junction zone.

The consensus statement builds on the 2015 designation of H. pylori gastritis as an infectious disease regardless of clinical symptoms or complications. “This represents a paradigm shift, as the indication for treatment is no longer reserved for patients with clinical manifestations of infection,” states the paper drawn up by 41 experts from 29 countries.

Australian senior author and Gut Editor-in-Chief Professor Emad El-Omar, the Director of the UNSW Microbiome Research Centre, says a key message is that gastroenterologists should treat H. pylori a pathogen that causes gastritis.

“This means a serious approach using best regimen on the first attempt,” he told the limbic.

“The standard, and widely used seven-day triple therapy, is increasingly failing, especially in countries with a clarithromycin resistance rate of  greater than 15%.”

He said data on clarithromycin resistance rates in Australia were “scant” and clinicians should not assume it is low. “In the absence of knowledge about clarithromycin resistance, we recommend bismuth-based quadruple therapy for 14 days,” he said. “This has a very high eradication rate.”

Professor El-Omar said this approach was available in Australia with additional paperwork, citing Category A form Special Access Scheme (SAS) requirements to prescribe tetracycline or De-Nol (bismuth subcitrate).

Test and treat approach

The consensus statement acknowledges widespread agreement that the test-and-treat strategy is appropriate for young patients experiencing new or recurrent dyspepsia who had no other symptoms.

But Professor El-Omar said an endoscopy was advisable for people aged older than 50 years, especially if there were other risk factors.

He said there was now ample evidence of how H. pylori infection caused gastric cancers.

“We now have a very clear picture of what goes on in the stomach in the presence of H. pylori, and especially after years of H. pylori-induced chronic gastritis, atrophy, metaplasia and cancer,” he said.

“H. pylori sets the scene of the crime. It causes chronic inflammation, destroys the acid secretory machinery and leads to an achlorhydric inflamed gastric environment in which trillions of nasty microbiota thrive. It is these nasty non-H. pylori gastric microbiota that drive progression towards the ultimate catastrophe of gastric cancer. This is why eradication of H. pylori infection holds the key to prevention of this global killer,” he said.

There was 100% or near universal agreement that the eradication of H. pylori was most effective for gastric cancer prevention before the development of severe chronic atrophic gastritis, and population-based H. pylori test-and-treat programs are cost-effective in populations with intermediate or high incidence of gastric cancer.

Examples of statements in Maastricht VI/Florence Consensus Report:

• Test-and-treat is an appropriate strategy for uninvestigated dyspepsia.
• H. pylori gastritis has to be excluded before a reliable diagnosis of functional dyspepsia can be made
• In young dyspeptic patients (age below 50) with no specific risk and no alarm symptoms, non-invasive testing for H. pylori infection is recommended.
• In dyspeptic patients older than 50 years, upper GI endoscopy is required. Functional serology may be considered as complementary diagnostic tool.
• UBT remains an important tool for H. pylori diagnosis before and after eradication therapy. Citric acid is an essential component of the protocol.
• The treatment duration of bismuth quadruple therapy should be 14 days, unless 10- days effective therapies are available.
• After failure of bismuth-containing quadruple therapy, a fluoroquinolone-containing quadruple (or triple) therapy, or the high-dose PPI-amoxicillin dual therapy may be recommended. In cases of high fluoroquinolone resistance, the combination of bismuth with other antibiotics, or rifabutin, may be an option.
• In choosing a non-bismuth quadruple therapy, concomitant therapy (PPI, amoxicillin, clarithromycin, and a nitroimidazole administered concurrently) should be the preferred choice given its proven reproducible effectiveness and less complexity compared with sequential and hybrid therapies.
• H. pylori eradication offers the chance for gastric cancer prevention at any age in adulthood. The magnitude of the benefit decreases with age.
• H. pylori eradication therapy has the potential to select resistant strains of gut microbiota