10 top tips - eradicating H. pylori

12 Dec 07

1

Test for H. pylori in any patient consulting with dyspepsia. The NICE guideline definition of dyspepsia includes symptoms of gastro-oesophageal reflux disease (GORD)1. In patients below the age of 55 and presenting with dyspepsia without serious or sinister symptoms, a test-and-treat strategy is more cost-effective than referral for endoscopy.

2

Stool antigen testing for H. pylori is the most sensitive and specific test for initial detection. Until recently the C13-urea breath test (UBT) was considered to be the gold standard non-invasive test for H. pylori. This is now being replaced by the monoclonal stool antigen test whose sensitivity and specificity has been reported to be 97% and 96% respectively. It is also cheaper, more accurate and easier than UBT. Check with your local lab about its availability.

3

Routine retesting for H. pylori to confirm eradication is unnecessary. Both the NICE and SIGN guidelines do not advocate routine retesting for H. pylori to confirm eradication. But in patients with persistent symptoms after eradication therapy, retesting and/or referral to specialist may be appropriate, especially if there is family history of ulcer disease or gastric cancer.

4

Either UBT or stool antigen test can be used to confirm eradication. UBT has been studied more than stool antigen testing after eradication but the differences are minimal. Wait for at least four weeks before retesting.

5

Serology testing for H. pylori now has little or no place in primary care. The much lower specificity of 80-85% quoted in most literature means some patients will be falsely diagnosed as having an infection and be given antibiotics inappropriately.

6

Check patients are not on proton pump inhibitors (PPIs) before UBT or stool antigen test. H. pylori thrives in the acid environment of stomach. Acid suppression therefore falsely reduces detection rates. Patient should not be on proton pump inhibitors for at least two weeks before testing.

7

Choose PAC (PPI, amoxicillin, clarithromycin) or PCM (PPI, clarithromycin, metronidazole) to eradicate H. pylori. Evidence for successful eradication is about 80% with either of the above two regimes used for seven days, twice daily. PCM is cheaper than PAC because the dose of clarithromycin used in PCM is 250mg rather than 500mg for PAC. But the risk of dual resistance developing to CM means it is probably better to initiate first-line therapy with PAC.

8

Fourteen-day therapy increases eradication rate by another 10% but may not be cost-effective.

In undiagnosed or uninvestigated dyspepsia the absolute benefit of 14-day therapy as first-line treatment is relatively modest and unlikely to be cost-effective. Despite this, European guidelines continue to recommend 14-day courses of treatment2.

9

Eradication can be useful in GORD.

The prevalence of H. pylori in patients with GORD is lower than those without GORD but eradication does not cause or exacerbate symptoms. In patients on long-term PPIs, it is suggested that testing and eradicating those positive for H. pylori will have a beneficial effect on the gastric mucosa and may lead to regression of gastric atrophy.

10

Chronic NSAID users might also benefit. H. pylori eradication is of value in chronic NSAID users but does not completely prevent NSAID-related ulcers. Routine H. pylori testing is not currently recommended for patients on long-term aspirin.

Dr Raghu Raghunath is a GP and hospital endoscopist in Hull and clinical senior lecturer at Hull York Medical School

References

1 NICE guideline. Dyspepsia: Managing dyspepsia in adults in primary care. July 2004. www.nice.org.uk
2 Malfertheiner P et al. Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report. Gut 2007;56:772-81