Advances in the Diagnosis and Therapy of Helicobacter pylori

Background: Helicobacter pylori infection infects approximately 50% of the world’s population, and is associated with significant morbidity and mortality. H. pylori infection is associated with large expenditures for diagnostic testing and prescription medication. Summary: The C13-urea breath test remains the non-invasive test with the highest sensitivity and specificity, and is the test-of-choice to confirm eradication following treatment. Although the stool antigen test is an acceptable alternative, care should be taken to only use kits with a documented accuracy >90%. Due to the increasing resistance to clarithromycin, the efficacy of standard clarithromycin-based triple therapy is now below 75%. Current guidelines recommend that such treatment only be used in regions where H. pylori resistance to clarithromycin is below 20%. Concomitant therapy and bismuth-based quadruple therapy yield superior eradication rates compared to standard triple therapy and sequential therapy. First line therapy tailored to cytochrome P450 2C19 (CYP2C19) phenotype and clarithromycin susceptibility may increase treatment success, however large, randomized controlled trials are lacking. Salvage therapy with fluoroquinalones is effective in about three quarters of patients, and is superior to bismuth-based quadruple therapy in this setting. Key messages: Clinicians must consider local antibiotic resistance patterns before choosing a particular regimen. In the absence of such information, clinicians should balance the need for a prolonged four-drug regimen against adverse effects and costs.