Management of Helicobacter Pylori in the United States: Results from a national survey of gastroenterology physicians

Racial disparities of gastric cancer in the USA: an overview of epidemiology, global screening guidelines, and targeted screening in a heterogeneous population

Gastric cancer is the fifth most common cancer diagnosis and fourth leading cause of cancer-related death globally. The incidence of gastric cancer in the USA shows significant racial and ethnic disparities with gastric cancer incidence in Korean Americans being over five times higher than in non-Hispanic whites. Since gastric cancer is not common in the USA, there are no current screening guidelines. In countries with higher incidences of gastric cancer, screening guidelines have been implemented for early detection and intervention and this has been associated with a reduction in mortality. Immigrants from high incidence countries develop gastric cancer at lower rates once outside of their country of origin, but continue to be at higher risk for developing gastric cancer. This risk does seem to decrease with subsequent generations. With increasing availability of endoscopy, initiating gastric cancer screening guidelines for high-risk groups can have the potential to improve survival by diagnosing and treating gastric cancer at an earlier stage. This article aims to provide context to gastric cancer epidemiology globally, review risk factors for developing gastric cancer, highlight racial and ethnic disparities in gastric cancer burden in the USA, examine current guidelines that exist in high incidence countries, and suggest future studies examining the efficacy of additional screening in high-risk populations to reduce gastric cancer mortality and disparate burden on ethnic minorities in the USA.

Type 2 Diabetes Mellitus and Helicobacter pylori Eradication in a Clinical Population

OBJECTIVES

Eradication of Helicobacter pylori reduces the risk of gastric cancer (GC). Individuals with type 2 diabetes mellitus (T2DM) are known to be at increased risk for GC. In a cohort of H. pylori-positive individuals, we assessed whether those with T2DM were at risk of persistent infection following H. pylori treatment compared with individuals without T2DM.

METHODS

A random subset of all individuals diagnosed as having H. pylori without intestinal metaplasia at endoscopy from 2015 to 2019 were stratified evenly by race (Black and White). After excluding those with T1DM and those without eradication testing after H. pylori treatment, logistic regression analysis was used to determine the association of T2DM with the risk of persistent H. pylori infection following treatment.

RESULTS

In 138 patients, H. pylori eradication rates did not differ between the 27% of individuals with T2DM compared to those without (81.1% vs 81.2%). After adjusting for age, race, and insurance status, we found no significant increased risk of persistent H. pylori infection for individuals with T2DM (odds ratio 1.40; 95% confidence interval 0.49-3.99).

CONCLUSIONS

H. pylori eradication rates do not differ by T2DM status, providing support for clinical trials of H. pylori eradication to reduce GC incidence among high-risk populations in the United States, such as individuals with T2DM.

Helicobacter pylori treatment knowledge, access and barriers: A cross-sectional study

BACKGROUND

Helicobacter pylori (Hp) is among the most common bacterial infections in the world and one of the most common infectious agents linked to malignancy, gastric cancer (GC). Within the US there is high disparity in the rates of Hp infection and associated diseases. Hp infection is treatable, and knowledge may influence screening and treatment seeking behaviors.

MATERIALS AND METHODS

In this cross-sectional study of 1042 respondents recruited from the Online Amazon MTurk platform, we sought to assess baseline knowledge of Hp and to gain insight into barriers related to Hp care.

RESULTS

Just over half (52.3%) reported some prior knowledge of Hp with 11.7% (n = 122) reporting being treated for Hp themselves and 21.4% reporting family members diagnosed with Hp. Of respondents reporting prior treatment, 95 (78%) reported GI upset and 27 (21%) reported not completing medications. Specific to Hp and GC, 70% indicated that a belief that the treatment was worse than the symptoms would affect their willingness to seek care, while 81% indicated knowing Hp can cause GC would affect their treatment decisions and knowing their gastric symptoms were caused by Hp would affect their willingness to receive care.

CONCLUSIONS

Knowledge of Hp in this US sample of online respondents is low and self-reported difficulties with treatment compliance is high. Increasing awareness of this infection and addressing the challenges to treatment compliance could potentially reduce rates of Hp antibiotic resistance and progression to GC or other complications of Hp infection.

Rates of Antimicrobial Resistance in Helicobacter pylori Isolates From Clinical Trial Patients Across the US and Europe

INTRODUCTION

Guidelines recommend that proton pump inhibitor-based triple regimens with clarithromycin not be used for Helicobacter pylori infection in areas where clarithromycin resistance is ≥15%, or in patients with prior macrolide use. Up-to-date information on local resistance patterns is limited, especially in the US. Here, we report resistance rates to antibiotics commonly used to treat H. pylori from a large study conducted in the US and Europe (pHalcon-HP).

METHODS

Gastric mucosal biopsies were collected from adult participants with H. pylori infection during screening. Minimum inhibitory concentrations were determined via agar dilution for clarithromycin, amoxicillin, and metronidazole, with breakpoints ≥1 μg/mL, >0.125 μg/mL, and >8 μg/mL, respectively. Resistance rates were obtained for the US and Europe, and also for US subregions and participating European countries.

RESULTS

Resistance rates were established in isolates from 907 participants. Overall, 22.2% were resistant to clarithromycin, 1.2% to amoxicillin, and 69.2% to metronidazole. Resistance in the US and Europe was similar; metronidazole resistance was the most prevalent (50%-79%) and amoxicillin the least (≤5%). In all subregions, ≥15% of isolates were resistant to clarithromycin, except the UK (0/8 isolates). Among clarithromycin-resistant isolates, 75% were also metronidazole-resistant. Two US isolates were resistant to clarithromycin and amoxicillin; one of these was also metronidazole-resistant.

DISCUSSION

The resistance rates observed in this study argue against the continued empiric use of proton pump inhibitor-based triple therapy containing clarithromycin, per treatment guidelines, and highlight the need for antibiotic resistance surveillance and novel treatment strategies for H. pylori infection in the US and Europe.

Diagnosis and treatment patterns among patients with newly diagnosed Helicobacter pylori infection in the United States 2016-2019

Approximately 36% of the United States (US) population is infected with Helicobacter pylori (HP), a known major risk factor for peptic ulcer disease and gastric cancer. HP eradication reduces the rate of complications; however, the benefits are undermined by rising rates of HP eradication treatment failure. This real-world observational cohort analysis aims to describe HP diagnostic and treatment patterns among insured patients in the US. Using diagnoses, lab results, and treatment patterns, we identified adults (18+) with new diagnoses of HP in the Veradigm Health Insights EHR Database linked to Komodo claims data (1/1/2016-12/31/2019). Patients were required to have ≥ 12 months of data pre-/post-index. We captured patient characteristics, HP-related diagnostic testing, and the use of US guideline-recommended HP eradication regimens. HP eradication rates following first-line eradication treatment were measured among patients with available lab results. Overall, 31.8% of the 60,593 included patients did not receive guideline-recommended treatment. Among the 68.2% (41,340) with first-line treatment, 80.2% received clarithromycin-based triple therapy, and 6.6% received bismuth quadruple therapy. Of the 4569 patients with a repeated course of eradication therapy, 53.4% received the same regimen as their first-line, the majority (90.7%) of whom received two rounds of clarithromycin-based triple therapy. Among the 2455 patients with results of HP non-serology testing following first-line treatment, the 180-day eradication rate was 80.2% overall, with differences based on treatments and demographics. This study highlights gaps between guideline-recommended HP management and real-world patterns, underscoring the need to improve HP testing, treatment, and follow-up practices.

An Approach to the Primary and Secondary Prevention of Gastric Cancer in the United States

BACKGROUND & AIMS

Gastric cancer (GC) remains a leading cause of mortality among certain racial, ethnic, and immigrant groups in the United States (US). The majority of GCs are diagnosed at advanced stages, and overall survival remains poor. There exist no structured national strategies for GC prevention in the US.

METHODS

On March 5-6, 2020 a summit of researchers, policy makers, public funders, and advocacy leaders was convened at Stanford University to address this critical healthcare disparity. After this summit, a writing group was formed to critically evaluate the effectiveness, potential benefits, and potential harms of methods of primary and secondary prevention through structured literature review. This article represents a consensus statement prepared by the writing group.

RESULTS

The burden of GC is highly inequitably distributed in the US and disproportionately falls on Asian, African American, Hispanic, and American Indian/Alaskan Native populations. In randomized controlled trials, strategies of Helicobacter pylori testing and treatment have been demonstrated to reduce GC-specific mortality. In well-conducted observational and ecologic studies, strategies of endoscopic screening have been associated with reduced GC-specific mortality. Notably however, all randomized controlled trial data (for primary prevention) and the majority of observational data (for secondary prevention) are derived from non-US sources.

CONCLUSIONS

There exist substantial, high-quality data supporting GC prevention derived from international studies. There is an urgent need for cancer prevention trials focused on high-risk immigrant and minority populations in the US. The authors offer recommendations on how strategies of primary and secondary prevention can be applied to the heterogeneous US population.

Worldwide Prevalence and Risk Factors of Helicobacter pylori Infection in Children

Helicobacter pylori is usually acquired during childhood. The reports from the last two decades pointed out a decrease in H. pylori prevalence across geographical areas worldwide compared to previously reported data. Most of the studies performed in America found an overall H. pylori infection prevalence of approximately 50%. The most important risk factors in America include being male, poor adherence or difficult access to treatment, and the lack of in-home water service. Despite the descending trend in prevalence worldwide, the overall prevalence in Africa remains very high (70%). Nevertheless, the prevalence of H. pylori in children without gastrointestinal who underwent screening was reported to be only 14.2%. The main risk factors in Africa are having a traditional pit or no toilet, poverty, birth order, source of drinking water, or being a farmer. Asia seems to have the widest variations in terms of H. pylori prevalence. Several risk factors were reported in Asia to be associated with this infection, such as lower income and educational level, house crowding, rural residence, ethnicity, the use of tanks as water supplies, alcohol drinking, active smoking, eating spicy food or raw uncooked vegetables, poor living conditions and sanitation. The overall prevalence of H. pylori infection in European children is almost 25%. Portugal has the highest prevalence of all European countries at 66.2% in children 13 years of age. The risk factors in European individuals consist of living in rural areas, eating unwashed fruits and vegetables, not washing hands after school, low parental education and unemployment, and short education duration. Further studies are required to identify the precise mechanisms involved in the discrepancies of H. pylori prevalence worldwide.

Vonoprazan Triple and Dual Therapy for Helicobacter pylori Infection in the United States and Europe: Randomized Clinical Trial

BACKGROUND & AIMS

Novel, effective treatments for Helicobacter pylori infection are needed. This study evaluated the efficacy of vonoprazan, a potassium-competitive acid blocker, vs standard treatment on H pylori eradication in the United States and Europe.

METHODS

In a randomized, controlled, phase 3 trial, treatment-naïve adults with H pylori infection were randomized 1:1:1 to open-label vonoprazan dual therapy (20 mg vonoprazan twice daily; 1 g amoxicillin 3 times daily), or double-blind triple therapy twice a day (vonoprazan 20 mg or lansoprazole 30 mg; amoxicillin 1 g; clarithromycin 500 mg) for 14 days. The primary outcome was noninferiority in eradication rates in patients without clarithromycin- and amoxicillin-resistant strains (noninferiority margin = 10%). Secondary outcomes assessed superiority in eradication rates in clarithromycin-resistant infections, and in all patients.

RESULTS

A total of 1046 patients were randomized. Primary outcome eradication rates (nonresistant strains): vonoprazan triple therapy 84.7%, dual therapy 78.5%, vs lansoprazole triple therapy 78.8% (both noninferior; difference 5.9%; 95% confidence interval [CI], -0.8 to 12.6; P < .001; difference -0.3%; 95% CI, -7.4 to 6.8; P = .007, respectively). Eradication rates in clarithromycin-resistant infections: vonoprazan triple therapy 65.8%, dual therapy 69.6%, vs lansoprazole triple therapy 31.9% (both superior; difference 33.9%; 95% CI, 17.7-48.1; P < .001; difference 37.7%; 95% CI, 20.5-52.6; P < .001, respectively). In all patients, vonoprazan triple and dual therapy were superior to lansoprazole triple therapy (80.8% and 77.2%, respectively, vs 68.5%, difference 12.3%; 95% CI, 5.7-18.8; P < .001; difference 8.7%; 95% CI, 1.9-15.4; P = .013). Overall frequency of treatment-emergent adverse events was similar between vonoprazan and lansoprazole regimens (P > .05).

CONCLUSION

Both vonoprazan-based regimens were superior to proton pump inhibitor-based triple therapy in clarithromycin-resistant strains and in the overall study population.

CLINICALTRIALS

gov; NCT04167670.

Current and Future Perspectives in the Diagnosis and Management of Helicobacter pylori Infection

Helicobacter pylori (Hp) is a prevalent organism infecting almost half the global population. It is a significant concern, given its associated risk of gastric cancer, which is the third leading cause of cancer death globally. Infection can be asymptomatic or present with dyspeptic symptoms. It may also present with alarm symptoms in the case of progression to cancer. Diagnosis can be achieved non-invasively (breath tests, stool studies, or serology) or invasively (rapid urease test, biopsy, or culture). Treatment involves acid suppression and regimens containing several antibiotics and is guided by resistance rates. Eradication is essential, as it lowers the risk of complications and progression to cancer. Follow-up after eradication is similarly important, as the risk of cancer progression remains. There have been many recent advances in both diagnosis and treatment of Hp. In particular, biosensors may be effective diagnostic tools, and nanotechnology, vaccines, and potassium-competitive acid blockers may prove effective in enhancing eradication rates.

Clinical practice of Helicobacter pylori infection management by gastroenterologists in secondary and tertiary hospitals: A stratified sampling cross-sectional survey

OBJECTIVE

To investigate the management of Helicobacter pylori (H. pylori) infection by gastroenterologists from secondary and tertiary hospitals in Shandong Province, China, where there is a high prevalence of H. pylori infection.

METHODS

A questionnaire-based, stratified sampling survey was conducted from June 1 to August 30, 2021. The ratio of secondary to tertiary hospitals was set at 2:1. An electronic questionnaire was sent to the gastroenterologists via the WeChat platform.

RESULTS

A total of 89.09% (1053/1182) gastroenterologists were included. Overall, 34.19% and 60.59% of gastroenterologists recommended screening for and treating H. pylori infection in patients without any competing factors. The most preferred testing method in secondary and tertiary hospitals was the ¹³ C-urea breath test (53.92% and 80.48%), but the reexamination rate of results close to the cut-off value was low (55.10% and 59.48%). Gastroenterologists preferred bismuth-containing quadruple therapy (secondary and tertiary hospitals: 96.67% and 98.53%), but the antibiotic combination prescribed for patients with penicillin allergy was suboptimal in secondary hospitals. The overall post-treatment follow-up rate was 64.58%, and gastroenterologists in secondary hospitals were more proactive than those in tertiary hospitals (69.41% vs 60.04%, P = 0.001). Less than 80% of gastroenterologists emphasized the importance of post-treatment reexamination to their patients. Only a minority of gastroenterologists in secondary and tertiary hospitals (30.79% and 34.36%) achieved acceptable eradication rates (exceeding 80%).

CONCLUSIONS

Deficiencies exist in gastroenterologists from secondary and tertiary hospitals, and the H. pylori eradication rate is relatively low. Training programs for gastroenterologists are warranted to strengthen their comprehension of guidelines.

Helicobacter pylori infection treatment in the United States: clinical consequences and costs of eradication treatment failure

INTRODUCTION

Helicobacter pylori (Hp) is causal in benign and malignant gastrointestinal diseases. Accordingly, current guidelines recommend Hp eradication in patients with active infection. Unfortunately, treatment failure is common, exposing patients to complications associated with persistent Hp infection and consequences of repeated treatment, including promotion of antibiotic resistance. In the United States (US), data regarding eradication rates with available therapies are limited. Moreover, the clinical and economic burden of eradication treatment failure have not been thoroughly described.

AREAS COVERED

We aimed to characterize Hp eradication rates and the clinical consequences and associated costs of persistent Hp infection among US adults. We conducted focused literature reviews using initial searches in Embase, MEDLINE, and Cochrane Database of Systematic Reviews via Ovid followed by manual searches to identify relevant publications.

EXPERT OPINION

Hp eradication rates were suboptimal, with most studies reporting rates ≤80% with clarithromycin-based triple therapy and bismuth quadruple therapy. There was direct evidence supporting numerous benefits of successful Hp eradication, including decreased risk of recurrent or complicated peptic disease and non-cardia gastric cancer. Cost benefits of eradication were related to mitigation of conditions associated with persistent Hp infection, (e.g. complicated peptic ulcer disease, and gastric cancer) which altogether exceed US$5.3 billion.

Diagnosis and Treatment of Helicobacter pylori Infection

The last 5 years have seen major shifts in defining whom to test and how to treat Helicobacter pylori infection. Peptic ulcer has changed from a chronic disease to a one-off condition, and countries with a high incidence of gastric cancer have begun implementing population-wide screening and treatment. A proactive approach to testing and treatment of H. pylori is now recommended, including outreach to family members of individuals diagnosed with active infection as well as high-risk local populations such as immigrants from high-risk countries. Increasing antimicrobial resistance has resulted in an overall decline in treatment success, causing a rethinking of the approach to development of treatment guidelines as well as the need to adopt the principles of antibiotic usage and antimicrobial stewardship. Required changes include abandoning empiric use of clarithromycin, metronidazole, and levofloxacin triple therapies. Here, we discuss these transformations and give guidance regarding testing and use of therapies that are effective when given empirically.

Treatment regimens used in the management of Helicobacter pylori in Colombia

Background

Helicobacter pylori infection can cause gastritis, gastric ulcers, duodenal ulcers, and gastric cancer. Its treatment involves different medications, but resistance to these treatments is increasing. It is currently considered a public health problem.

Aims

to identify regimens used for H. pylori eradication by age group, year of treatment and geographical region of Colombia.

Methods

A cross-sectional study that identified regimens used H. pylori eradication in outpatient consultations over a 6-year period based on a medication dispensing database of 8.5 million people affiliated to the Colombian Health System. The appropriate regimens were those that included a proton pump inhibitor, associated with two antibiotics recommended by clinical practice guidelines (amoxicillin, clarithromycin, levofloxacin, moxifloxacin, tetracycline, doxycycline, metronidazole, tinidazole, and furazolidone).

Results

A total of 12,011 patients with a diagnosis of acid-peptic disease and H. pylori infection were identified, who had undergone 12,426 eradication treatment courses. Of these, 98.0% used a proton pump inhibitor (PPI), and 91.1% used amoxicillin. A total of 56.1% of the regimens were considered adequate; of these, 42.0% were a combination of PPI, amoxicillin/clarithromycin. This regimen predominated between 2015 and 2017 for all age groups.

Conclusions

The management of H. pylori infection in the majority of patients is heterogeneous and inconsistent with current recommendations based on evidence of antimicrobial resistance.

Three-Decade Failure to the Eradication of Refractory Helicobacter pylori Infection and Recent Efforts to Eradicate the Infection

BACKGROUND

Helicobacter pylori causes dangerous and deadly diseases such as gastric cancer and duodenal ulcers. Eradication and treatment of this bacterium are very important due to the deadly diseases caused by H. pylori and the high cost of treatment for countries.

METHODS

Thus, we present a complete list of the most important causes of failure in the treatment and eradication of H. pylori, and address new therapeutic methods that may be effective in controlling this bacterium in the future.

RESULTS

Many efforts have been made to control and eradicate this bacterium over the years, but no success has been achieved since its eradication is a complex process affected by the bacterial properties and host factors. Previous studies have shown that various factors are involved in the failure to eradicate H. pylori, such as new genotypes of the bacterium with higher pathogenicity, inappropriate patient cooperation, mutations, biofilm formation and dormant forms that cause antibiotic resistance, acidic stomach pH, high bacterial load, smoking, immunosuppressive features and intracellular occurrence of H. pylori. On the other hand, recent studies reported that the use of probiotics, nanoparticles, antimicrobial peptides, natural product and vaccines can be helpful in the treatment and eradication of H. pylori infections.

CONCLUSION

Eradication of H. pylori is crucial for the treatment of important diseases such as gastric cancer. Therefore, it seems that identifying the failure causes of treating this bacterium can be helpful in controlling the infections. Besides, further studies on new therapeutic strategies may help eradicate H. pylori in the future.

Single-Center Review of Appropriateness and Utilization of Upper Endoscopy in Dyspepsia in the United States

Background

We compared real-world practice of dyspepsia management to the new American College of Gastroenterology (ACG)/Canadian Association of Gastroenterology (CAG) guidelines 2017.

Methods

We conducted a retrospective, observational study using administrative data to include patients undergoing esophagogastroduodenoscopy (EGD) for dyspepsia.

Results

Out of 122 EGDs, only 30 (24.5%) were deemed appropriate per guidelines. Only 13 (14.1%) patients had undergone both Helicobacter pylori (H. pylori) test and treat and adequate proton pump inhibitor (PPI) before undergoing endoscopy. Nineteen (15.5%) patients had alarm symptoms (weight loss, melena and early satiety). Positivity rate of H. pylori was 36.3%, but only half completed treatment. Twenty-six patients (21.3%) had abnormalities on endoscopy, most commonly gastritis. There were no cases of gastric/esophageal cancer.

Conclusions

The rate of inappropriate upper gastrointestinal endoscopy is higher than the existing literature, likely because of the stricter use of EGD in patients < 60 years. Only one in eight patients underwent the recommended workup before undergoing endoscopy.

AGA Clinical Practice Update on the Management of Refractory Helicobacter pylori Infection: Expert Review

The purpose of this CPU Expert Review is to provide clinicians with guidance on the management of Helicobacter pylori after an initial attempt at eradication therapy fails, including best practice advice on specific regimen selection, and consideration of patient and systems factors that contribute to treatment efficacy. This Expert Review is not a formal systematic review, but is based upon a review of the literature to provide practical advice. No formal rating of the strength or quality of the evidence was carried out. Accordingly, a combination of available evidence and consensus-based expert opinion were used to develop these best practice advice statements.

The Durham Initiative for Stomach Health (DISH): a pilot community-based Helicobacter pylori education and screening study

Background

Approximately 15% of all cancers are due to infection. The bacteria Helicobacter pylori is the single leading carcinogenic infectious agent and the main cause of stomach cancer. Prevalence of H. pylori, and, correspondingly, stomach cancer incidence and mortality, is significantly greater among African Americans than whites in the United States. In the present study, we conducted a pilot community-engaged H. pylori education and screening study in partnership with a predominantly African American church in Durham, North Carolina.

Methods

Initially, we consulted with community advisory boards and convened stakeholder meetings with local community members and primary care physicians. We then developed this pilot study through an iterative collaboration with church partners. Our main outcomes were feasibility and acceptability as measured by participation in a one-day H. pylori screening initiative, and participation in follow-up for those who tested positive. We also sought to determine prevalence and determinants of active H. pylori infection in this population.

Results

Community engagement informed the event logistics, messaging, educational materials provided, and follow-up plans. A total of 92 individuals participated in the primary study event, 25% of whom had a current H. pylori infection. Of those, 87% returned for the follow-up events, among whom 70% had successfully cleared their infection.

Conclusions

Through community engagement, community-based H. pylori screening and stomach cancer prevention is feasible and acceptable. This is a necessary step in order to move stomach cancer prevention forward to population-based precision H. pylori screening and eradication.

Physicians' adherence to management guidelines for H. pylori infection and gastroesophageal reflux disease: a cross-sectional study

BACKGROUND

Primary care physicians (PCPs) play a pivotal role in the management of illnesses of the digestive tract. The study aim was to assess the adherence of PCPs to the guidelines on the management of Helicobacter pylori (H. pylori) infection and gastroesophageal reflux disease (GERD) in adults.

METHODS

We conducted a cross-sectional study during March-July 2017 using the survey platform of Maccabi Healthcare Services in Israel. The study questionnaire assessed adherence to the Maastricht/Florence guidelines on H. pylori infection and the American College of Gastroenterology guidelines on the management of GERD. We sent the study questionnaires to a random sample of 610 PCPs via electronic mails. We contacted those who did not respond by telephone; eventually 180 physicians completed the survey.

RESULTS

Ninety (50%) and 60 (36%) of the responders reported using professional guidelines for the diagnosis and management of H. pylori infection and GERD, respectively. Of the 180 participants, 153 (85%) reported referring patients with suspected peptic ulcer disease to H. pylori testing, 109 (61%) reported referring patients with unexplained iron deficiency anemia and 83 (46%) refer relatives of gastric cancer patients. In caring for young patients who have dyspepsia without alarm symptoms, 127 (74%) reported referral to a urea breath test for the diagnosis of H. pylori infection, and 136 (81%) referral to a specialist in gastroenterology if alarm symptoms present. Triple therapy with proton pump inhibitors/clarithromycin/amoxicillin or metronidazole was reported as first-line therapy by 141 (83%) participants. For GERD, 94-98% of the participants followed the appropriate recommendations.

CONCLUSIONS

We identified gaps between the practices of PCPs and the guidelines on H. pylori infection management, while guidelines on GERD management are well adopted. Simplification of the guidelines and exploring barriers towards their implementation by PCPs is warranted.

Management of Helicobacter pylori infection by clinicians: A nationwide survey in a developing country

BACKGROUND & AIMS

Developing countries are making efforts to improve health management. Practice deviating from the guideline means inefficient control. The study aims to investigate the management of Helicobacter pylori (H pylori) infection from a developing country perspective.

METHODS

An authoritative survey was conducted in 14th (2014) and 17th (2017) Congress of Gastroenterology China, respectively. The Maastricht V/Florence consensus report was invoked as the evaluation criterion.

RESULTS

A total of 4182 valid samples were included in this study. Most of the respondents (94%) updated knowledge by lectures. Respondents had a different awareness rate of H pylori-related diseases, ranging from 45% to 95%. Up to 40% of the respondents did not follow the recommendations for the diagnosis. Choice accuracy of eradication regimens and antibiotic combinations was <70%. About 20% of the respondents did not pay attention to the confirmation after the eradication. The situation had been improved in 2017 when compared with that in 2014 (all P < .05). Multivariate logistic regression analysis revealed that influencing factors including nongastroenterologists, bachelor degree and below, the primary professional title, hospital location, and a small proportion of H pylori infection in daily practice related to the deviation of consensus (all P < .05).

CONCLUSIONS

Although the management of H pylori infection has been improved in a developing country, there is still a gap between the real-world practices and the consensus. Influencing factors should be taken into account in decision-making, and the corresponding population should be strengthened with precision training during the promotion of the guideline.

Ethnic Disparities in Gastric Cancer Presentation and Screening Practice in the United States: Analysis of 1997-2010 Surveillance, Epidemiology, and End Results-Medicare Data

BACKGROUND

Chronic infection with Helicobacter pylori (H. pylori) is the strongest risk factor for distal gastric cancer. Although gastric cancer incidence has decreased, variation by race and ethnicity is observed. This study describes gastric cancer presentation and screening services among Medicare patients by race/ethnicity, place of birth, and history of gastric cancer-related conditions.

METHODS

Using demographic, location, and disease staging information, extracted from the Surveillance, Epidemiology and End Results-Medicare gastric cancer database (1997-2010), we compared frequencies of gastric cancer-related conditions (e.g., peptic ulcer, gastric ulcer, gastritis) and screening (H. pylori testing and endoscopy) from inpatient and outpatient services claims by selected race/ethnicity and place of birth.

RESULTS

Data included 47,994 incident gastric cancer cases with Medicare claims. The majority (48.0%) of Asian/Pacific Islanders (API) were foreign-born, compared with non-Hispanic whites (NHW), Hispanics, and blacks (with 64.4%, 33.9%, and 72.9% U.S.-born, respectively). For NHWs, the most frequently diagnosed gastric cancer site was the cardia (35.6%) compared with <15% (P < 0.001) for APIs, Hispanics, and blacks. Although more than 57% of all cases had a history of gastric cancer-related conditions, H. pylori testing was reported in only 11.6% of those cases. H. pylori testing was highest for APIs (22.8%) and lowest for blacks (6.5%).

CONCLUSIONS

Noncardia gastric cancer, associated with H. pylori infection, was diagnosed more frequently among APIs, blacks, and Hispanics than NHWs. Testing for H. pylori was low among all gastric cancer cases despite evidence of risk factors for which screening is recommended. Studies are needed to increase appropriate testing for H. pylori among higher risk populations.

IMPACT

This study sheds light on poor screening practices despite presence of gastric cancer-related conditions.

Helicobacter pylori infection progresses proximally associated with pyloric metaplasia in age-dependent tendency: a cross-sectional study

Background

The elderly population presents higher morbidity of H. pylori associated diseases in proximal stomach. The specific pathogenesis and mechanism have not been clearly addressed. The gastric environment for H. pylori colonization is dynamic with increasing age. The aim of present study is to investigate the correlation among the distribution of H. pylori, mucosal inflammation, gastric microenvironment and age.

Methods

A total of 180 patients with dyspepsia symptoms were divided into young, middle-aged and elderly groups. Biopsies were obtained from each patient in five locations: great curvature (mid-corpus, mid-antrum), lesser curvature (mid-corpus, mid-antrum) and incisura angularis (IA), analyzed for H. pylori density, mucosal inflammation and histopathology.

Results

The infection rate of H. pylori increased linearly with age (p <  0.001) in corpus, but not in antrum and IA. The H. pylori density was significantly aggravated in IA (p = 0.002) and corpus (p <  0.001) in elderly patient, but not in antrum. The mucosa inflammation scores were consistent with the severity of H. pylori colonization among three age groups. In elderly patients, the pyloric glands present more frequently in corpus, comparing with young and middle-aged group. A significant positive correlation among aggravating severity of H. pylori infection, mucosal inflammation and pyloric metaplasia in corpus with increasing age (p <  0.001) was occurred.

Conclusions

With increasing age, both topographic distribution of H. pylori and the expansion of pyloric glands increased in a distal-to-proximal gastric direction. Pyloric metaplasia in corpus was correlated with the risk of aggravated H. pylori colonization and associated inflammation in elderly population.

Houston Consensus Conference on Testing for Helicobacter pylori Infection in the United States

Despite guidelines for detection and treatment of Helicobacter pylori infection, recommendations to test patients before and after therapy are commonly not followed in the United States. At the Houston Consensus Conference, 11 experts on management of adult and pediatric patients with H pylori, from different geographic regions of the United States, met to discuss key factors in diagnosis of H pylori infection, including identification of appropriate patients for testing, effects of antibiotic susceptibility on testing and treatment, appropriate methods for confirmation of infection and eradication, and relevant health system considerations. The experts divided into groups that used a modified Delphi panel approach to assess appropriate patients for testing, testing for antibiotic susceptibility and treatment, and test methods and confirmation of eradication. The quality of evidence and strength of recommendations were evaluated using the GRADE system. The results of the individual workshops were presented for a final consensus vote by all panel members. After the Expert Consensus Development meeting, the conclusions were validated by a separate panel of gastroenterologists, who assessed their level of agreement with each of the 29 statements developed at the Expert Consensus Development. The final recommendations are provided, on the basis of the best available evidence, and provide consensus statements with supporting literature to implement testing for H pylori infection at health care systems across the United States.

Inappropriate treatment in Helicobacter pylori eradication failure: a retrospective study

BACKGROUND

In recent years, success rates of empirical H. pylori therapies have fallen in many countries. Although antibiotic resistance and poor adherence are described as the main factors for treatment failure, in China, iatrogenic factors also play an important role.

OBJECTIVE

To investigate why patients experienced multiple failures, we performed a retrospective, single center study using questionnaires to identify causes of treatment failure other than antibiotic resistance.

METHODS

This study was conducted from January 2016 to July 2017 in a general hospital. Patients with at least two H. pylori treatment failures who completed the questionnaire were entered. The survey covered characteristics of the study population, regimens used, and adherence to therapy.

RESULTS

Two hundred and ninety three patients were included in the final analysis. The top three most antibiotic combinations as the first-line treatment were a PPI plus clarithromycin-metronidazole (24.6%, 72/293), clarithromycin-levofloxacin (23.5%, 69/293) and clarithromycin-amoxicillin (21.5%, 63/293). Clarithromycin-containing regimens were repeatedly used in 178 patients (60.8%) and levofloxacin-containing regimens repeatedly in 88 patients (30.0%). Fifty patients (17.1%) had poor adherence per treatment history and 32 (10.9%) stopped treatment because of nonmedical reasons.

CONCLUSIONS

In order to increase the success of H. pylori eradication therapy, the effect of prior therapies needs to be given more consideration. Patient education to enhance adherence also needs to be improved.

The effect of virulence genotypes of Helicobacter pylori on eradication therapy in children

BACKGROUND/AIM

It is important to eradicate Helicobacter pylori at an early stage in patients during childhood to potentially prevent the development of H. pylori-related diseases. Studies have demonstrated that the virulence genotype of H. pylori influences the efficacy of eradication therapy. The efficacy of triple therapy has decreased significantly, which has seriously affected the clinical outcome of children with H. pylori infection. In this study we aimed to investigate the influence of virulence genotypes of H. pylori on triple eradication therapy in children.

PATIENTS AND METHODS

H. pylori strains were isolated from the gastric antrum mucosa in children with upper gastrointestinal symptoms. Polymerase chain reaction (PCR) was conducted to determine the H. pylori cagA, vacA, and iceA genotypes. All patients with H. pylori infection were administered 14-day triple therapy. After drug withdrawal for at least 4 weeks, the ¹³C-urea breath test (¹³C-UBT) was used to observe the therapeutic effect of H. pylori eradication. The eradication rates were evaluated by intention-to-treat (ITT) and per-protocol (PP) analyses.

RESULTS

A total of 107 patients were enrolled in this study. Nine patients were lost to follow-up, and 98 patients were administered eradication therapy. Based on ITT and PP analyses, the H. pylori eradication rate was 64.5% (69/107) and 70.4% (69/98), respectively. Among the successful eradication groups, the cagA-positive, vacA s1a, vacA s1c, vacA m1, vacA m2, iceA 1, and iceA 2 genes were identified in 72.8%, 68.1%, 76.9%, 60.0%, 74.6%, 71.8%, and 75.0% of strains, respectively. Of the unsuccessful eradication groups, the cagA-positive, vacA s1a, vacA s1c, vacA m1, vacA m2, iceA 1, and iceA 2 genes were identified in 27.2%, 31.9%, 23.1%, 40.0%, 25.4%, 28.2%, and 25.0% of strains, respectively. No statistically significant differences were noted in the detection rate of the H. pylori genotypes between the H. pylori successful and unsuccessful eradication groups (P > 0.05).

CONCLUSIONS

The cagA, vacA, and iceA genotypes of H. pylori are not associated with the efficacy of omeprazole-based triple therapy on the eradication of H. pylori infection in children.