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Treating Helicobacter Pylori Effectively While Minimizing Misuse of Antibiotics

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Treating Helicobacter Pylori Effectively While Minimizing Misuse of Antibiotics REVIEW EDUCATIONAL OBJECTIVE: Readers will treat Helicobacter pylori infections according to likely susceptibility to antibiotics AKIKO SHIOTANI, MD, PhD HONG LU, MD, PhD MARIA PINA DORE, MD, PhD DAVID Y. GRAHAM, MD Professor, Department of Internal GI Division, Ren Ji Hospital, School of Medicine, GI Fellowship Program Director, Dipartimento Department of Medicine, Michael E. Medicine, Kawasaki Medical School, Shanghai Jiao Tong University, Shanghai Institution di Medicina Clinica e Sperimentale, Clinica DeBakey VAMC, and Professor, Baylor Okayama, Japan of Digestive Disease; Key Laboratory of Gastroen- Medica, University of Sassari, Sassari, Italy College of Medicine, Houston, TX terology & Hepatology, Ministry of Health, Shang- hai, China; Vice-director of Chinese H pylori Study Group of Chinese Society of Gastroenterology Treating Helicobacter pylori effectively while minimizing misuse of antibiotics ABSTRACT elicobacter pylori infection is an in- H fectious disease and should be treated Experts now recommend that all Helicobacter pylori like one, with due consideration of antibiotic infections be eradicated unless there are compelling resistance and stewardship.1–4 reasons not to. As with other infectious diseases, effective This was the consensus of the 2015 Kyoto therapy should be based on susceptibility. H pylori conference,2 and it signaled a funda- mental shift in thinking. Up to now, H pylori KEY POINTS treatment has not been based on infectious We recommend clinicians have 2 fi rst-line options to ac- disease principles, leading to suboptimal re- commodate prior antibiotic use or drug allergy. sults and antibiotic resistance. In addition, the conference recommended that H pylori infec- tion be treated whenever it is found unless We recommend 4-drug combinations as fi rst-line treat- there are compelling reasons not to. ments, ie, either concomitant therapy or bismuth-contain- Here we review current and possible future ing quadruple therapy, to be taken for 14 days. regimens for eradicating H pylori that we hope will be more effective and will lead to less re- Concomitant therapy consists of the combination of sistance than in the past. amoxicillin, metronidazole, clarithromycin, and a proton pump inhibitor. ■ H PYLORI AS AN INFECTIOUS DISEASE Not until the late 1980s was H pylori recog- Bismuth quadruple therapy consists of the combination nized as the cause of peptic ulcer disease, of bismuth, tetracycline, metronidazole, and a proton which until then accounted for hundreds of pump inhibitor. thousands of hospitalizations and more than 100,000 surgical procedures each year.5 Now, peptic ulcer disease is routinely treated by After 2 treatments have failed, therapy with different H pylori. regimens should be based on susceptibility testing. eradicating In addition, the World Health Organization has recommended con- sidering H pylori eradication to reduce the risk of gastric cancer,6 which causes 738,000 deaths worldwide per year.7 Dr. Graham is supported in part by the Offi ce of Research and Development Medical Research The problems of how to diagnose and treat Service Department of Veterans Affairs, Public Health Service grants R01 DK062813 and DK56338 H pylori infection were taken on by gastro- which fund the Texas Medical Center Digestive Diseases Center. The contents are solely the responsibility of the authors and do not necessarily represent the offi cial views of the Veterans enterologists, and not by specialists in infec- Administration or National Institutes of Health. tious disease.1 Even now, almost all the major Dr. Graham is a consultant for BioGaia, RedHill Biopharma, and Takeda Pharmaceutical Ltd. reviews and consensus statements on H pylori doi:10.3949/ccjm.84a.14110 come from gastroenterologists and are pub- 310 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 84 • NUMBER 4 APRIL 2017 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. SHIOTANI AND COLLEAGUES lished in gastroenterology journals.2,8,9 As discussed below, all recent guidelines But infectious diseases differ from most gas- have recommended 4-drug non-bismuth-con- trointestinal diseases. In gastrointestinal prob- taining concomitant therapy as fi rst-line ther- lems such as constipation or infl ammatory bow- apy. An infectious disease colleague described el disease,10 the causes are generally unknown, it as a “hope therapy” because the prescriber and there is a large placebo response to therapy. hoped that the infection would be susceptible In contrast, in infectious diseases, the cause is to either metronidazole or clarithromycin. All generally known, there is no placebo response, who receive this combination receive an anti- and treatment success depends on susceptibility biotic they do not need. This is an expedient of the organism. Failure of proven regimens is rather than a medically rational choice result- generally due to resistant organisms, poor adher- ing from failure to deal with H pylori as an in- ence, or, in the case of H pylori, poorly designed fectious disease. regimens in terms of doses, frequency of admin- istration, or duration of therapy. ■ H PYLORI THERAPIES The differences extend to clinical trials of Conceptually, treating infectious disease is treatment.3 In other infectious diseases, treat- straightforward: one should prescribe antimi- ment is based on susceptibility. The usual crobial drugs to which the organism is suscep- comparative approach in infectious diseases is tible3 (Table 1). However, clinical success lies a noninferiority trial in which the new treat- in the details, which include the doses, fre- ment is compared with standard care, ie, a quency of doses, duration of therapy, timing regimen that reliably achieves nearly 100% of doses in relation to meals, and use of ad- cure rates. Not so with H pylori. Most trials of juvants such as antisecretory drugs, antacids, H pylori therapy compared regimens in popu- and probiotics. A number of regimens reliably lations with high but unknown prevalences of resistance and therefore are of limited or no yield high cure rates—95% or higher—if the help to the clinician in choosing the best regi- organism is susceptible and the patients are men for an individual patient.3 adherent. Many thousands of H pylori-infected pa- The effectiveness of any regimen may vary Only regimens depending on the population it is used in, due tients participated in clinical trials in which proven to the results would have been predictable if the to polymorphisms in drug-metabolizing en- researchers had assessed susceptibility before zymes such as CYP2C19. provide cure giving the drugs.11–13 Worse, many patients Sequential therapy is obsolete rates > 90% were also randomized to receive regimens that H pylori Sequential therapy for infection (preferably the investigators knew provided poor cure consisted of amoxicillin plus a proton pump rates in the population being studied. This inhibitor for 7 days, followed by clarithromy- > 95%) with knowledge was generally not shared with the cin, tinidazole, or metronidazole plus a pro- susceptible patients. This approach was used to demon- ton pump inhibitor for a further 7 days. This strate that a new regimen was superior to an regimen should not be used any more because strains should old one, even though the new one was already concomitant therapy will always be superior be prescribed known to be less affected by resistance to the (see below). key element in the comparator. Clinicians generally do not test for suscepti- Need for 14 days of therapy bility when treating H pylori, one reason being H pylori occupies a number of different niches that such testing is often unavailable.3 How- in the body ranging from gastric mucus (which ever, almost every hospital, clinic, and major is technically outside the body) to inside gas- laboratory in the world provides susceptibility tric epithelial cells. As a general rule, 14-day testing for other common local pathogens. H therapy provides the best results, in part be- pylori is easy to grow, and laboratories could test cause the longer duration helps kill the organ- for susceptibility if we asked them to. isms that persist in different niches.14,15 Current H pylori recommendations may In addition, proton pump inhibitors, which also contribute to the global increase in anti- are part of all the currently recommended regi- microbal resistance. mens, require 3 or more days to reach their full CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 84 • NUMBER 4 APRIL 2017 311 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. ANTIBIOTIC RECOMMENDATIONS FOR H PYLORI TABLE 1 How to choose a therapy Since rational infectious-disease therapy is Recommended regimens for Helicobacter pylori based on susceptibility, one should start by considering the susceptibility pattern in the Susceptibility-based, for patients with no drug allergies local population and, therefore, the likely sus- Clarithromycin triple therapy ceptibility in the patient in front of us. (For infections susceptible to clarithromycin) Unfortunately, we do not yet have local or All of the following twice daily for 14 days: regional susceptibility data on H pylori for most Clarithromycin 500 mg locales. Until those data are available, we must Amoxicillin 1 g use the indirect information that is available, A proton pump inhibitor a such as the patient’s history of antibiotic use. Metronidazole triple therapy (For infections susceptible to metronidazole)
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