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

Quality appraisal of clinical guidelines for Helicobacter pylori infection and systematic analysis of the level of evidence for recommendations

OBJECTIVES

To systematically assess the quality of clinical practice guidelines (CPGs) for Helicobacter pylori (HP) infection and identify gaps that limit their development.

STUDY DESIGN AND SETTING

CPGs for HP infection were systematically collected from PubMed, Embase, the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature, and six online guideline repositories. Three researchers independently used the AGREE Ⅱ tool to evaluate the methodological quality of the eligible CPGs. In addition, the reporting and recommendation qualities were appraised by using the RIGHT and AGREE-REX tools, respectively. The distribution of the level of evidence and strength of recommendation among evidence-based CPGs was determined.

RESULTS

A total of 7,019 records were identified, and 24 CPGs met the eligibility criteria. Of the eligible CPGs, 19 were evidence-based and 5 were consensus-based. The mean overall rating score of AGREE II was 50.7% (SD = 17.2%). Among six domains, the highest mean score was for scope and purpose (74.4%, SD = 17.7%) and the lowest mean score was for applicability (24.3%, SD = 8.9). Only three of 24 CPGs were high-quality. The mean overall score of recommendation quality was 35.5% (SD = 12.2%), and the mean scores in each domain of AGREE-REX and RIGHT were all ≤ 60%, with values and preferences scoring the lowest (16.6%, SD = 11.9%). A total of 505 recommendations were identified. Strong recommendations accounted for 64.1%, and only 34.3% of strong recommendations were based on high-quality evidence.

CONCLUSION

The overall quality of CPGs for HP infection is poor, and CPG developers tend to neglect some domains, resulting in a wide variability in the quality of the CPGs. Additionally, CPGs for HP infection lack sufficient high-quality evidence, and the grading of recommendation strength should be based on the quality of evidence. The CPGs for HP infection have much room for improvement and further researches are required to minimize the evidence gap.

Impact of medical conjoined mode on standardized diagnosis and treatment of Helicobacter pylori infection by primary doctors

BACKGROUND

Helicobacter pylori (H. pylori) infection has close relationship with chronic nonerosive gastritis, peptic ulcer, and gastritc cancer. The great majority of patients with H. pylori infection first visit grass-root health centers, where the diagnostic and therapeutic procedure of H. pylori infection is not standard. This study aimed to enhance the levels of diagnosis and treatment of H. pylori infection by standardized management and training of grassroots doctors under medical conjoined mode.

AIM

To investigate the effect of medical conjoined mode on the standardized diagnosis and treatment of H. pylori infection by primary doctors.

METHODS

Totally 112 primary doctors at our hospital and associated community service centers were selected. The primary doctors received a 3-d rotation training about the standar-dized diagnosis and treatment of H. pylori infection within 6 mo. The understanding and application of the Fifth Chinese National Consensus on the Management of H. pylori Infection (Fifth Consensus) among the primary doctors were compared before and after the training.

RESULTS

A total of 106 primary doctors completed the rotation training and questionnaire survey. The understanding and application of the Fifth Consensus among the primary doctors were poor before training. The Fifth Consensus has not been fully applied to the clinical diagnosis and treatment by primary doctors. After intervention, the understanding and application of the Fifth Consensus among the primary doctors were significantly improved compared with those before intervention(P < 0.01 and P < 0.05, respectively). About 88.24% of the primary doctors thought that the training was extremely essential, 87.25% considered that the result of the training was fairly satisfactory, and 95.10% approved the training model.

CONCLUSION

The primary doctors have low compliance to the Fifth Consensus, and their diagnosis and treatment of H. pylori infection are nonstandard. The medical conjoined mode can improve the understanding of the Fifth Consensus among primary doctors and enhance their levels of diagnosis and treatment of H. pylori infection.

Colloidal bismuth pectin-containing quadruple therapy as the first-line treatment of Helicobacter pylori infection: A multicenter, randomized, double-blind, non-inferiority clinical trial

BACKGROUND

Bismuth-containing quadruple therapy is an effective regimen for Helicobacter pylori (H. pylori) treatment. No head-to-head comparison trials have been conducted to evaluate the efficacy of colloidal bismuth pectin (CBP) in quadruple therapy for eradicating H. pylori. We aimed to compare the efficacy and safety of CBP quadruple therapy and bismuth potassium citrate (BPC) quadruple therapy for 14 days in the first-line treatment of H. pylori.

METHODS

In this multicenter, randomized, double-blind, non-inferiority clinical trial, H. pylori-infected subjects without eradication history were randomized to receive amoxicillin 1 g twice daily, tetracycline 500 mg three time daily, esomeprazole 20 mg twice daily in combination with CBP 200 mg three time daily or BPC 240 mg twice daily for 14 days. ¹³ C-urea breath tests were used to access the eradication rate at least 4 weeks after treatment.

RESULTS

Between April 2021 and July 2022, 406 patients were assessed for eligibility and 339 subjects were randomized. The cure rates (primary outcome) of CBP and BPC quadruple therapy were 90.5% and 92.3% (p = 0.56) by intention-to-treat analysis, respectively, and 96.1% and 96.2% (p = 1.00) by per-protocol analysis, respectively. CBP quadruple therapy was non-inferior to BPC quadruple therapy in the intention-to-treat and per-protocol analysis (p < 0.025). The frequency of adverse events and compliance were not different among the two groups (p > 0.05).

CONCLUSIONS

Both CBP and BPC quadruple therapy for 14 days provide high efficacy, good compliance, and safety in the first-line treatment of H. pylori in China.

Diagnosis and Treatment of Helicobacter pylori Infection in Real Practice-New Role of Primary Care Services in Antibiotic Resistance Era

Helicobacter pylori (H. pylori) is a key agent in several upper gastrointestinal diseases. Treatment of H. pylori infection is the main strategy for resolving the associated gastroduodenal damage in infected patients and for the prevention of gastric cancer development. Infection management is becoming complex due to the increase in antibiotic resistance, which already represents a global healthcare problem. Resistance to clarithromycin, levofloxacin or metronidazole have forced the adaptation of eradication regimens in this new reality to reach the eradication rate target recommended in most international guidelines (>90%). In this challenging scenario, molecular methods are revolutionizing the diagnosis of antibiotic-resistant infections and the detection of antibiotic resistance and opening a path towards personalized treatments, although their use is not yet widespread. Moreover, the infection management by physicians is still not adequate, which contributes to aggravating the problem. Both gastroenterologists and mainly primary care physicians (PCPs), who currently routinely manage this infection, perform suboptimal management of the diagnosis and treatment of H. pylori infection by not following the current consensus recommendations. In order to improve H. pylori infection management and to increase PCPs' compliance with guidelines, some strategies have been evaluated with satisfactory results, but it is still necessary to design and evaluate new different approaches.

Iatrogenic factors of Helicobacter pylori eradication failure: lessons from the frontline

BACKGROUND

Iatrogenic factors play an important role in H. pylori eradication failure, whereas it can be easily missed. Therefore, we aimed to investigate and analyze these related iatrogenic factors of H. pylori eradication failure.

METHODS

A total of 508 patients who experienced H. pylori eradication failure were included in this study conducted from December 2019 to February 2022. All the patients filled out a questionnaire including demographic characteristics, duration of treatment, regimens, dosage, and time intervals in rescue treatment.

RESULTS

In the first-line treatment, 89 patients (17.5%, 89/508) used at least one antibiotic with high resistance rate in triple therapy and 57 patients (11.2%, 57/508) used two antibiotics with high resistance rates or other not recommended antibiotics in quadruple therapy. In the rescue therapy, 85 regimens were repeatedly used as salvage regimens in 58 patients (22.6%, 58/257) and 178 regimens containing antibiotics with high resistance rates were repeatedly used in 85 patients (33.1%, 85/257).

CONCLUSION

To decrease the risk of H. pylori eradication failure, iatrogenic factors need to gain more attention. Clinicians should enhance their education and training to standardize the treatment regimens, better manage the H. pylori infection, and improve the eradication rate eventually.

Knowledge and Perception of Physicians of Different Specialties in Saudi Arabia Toward Helicobacter pylori

Background

Helicobacter pylori (H. pylori) is a key pathogen causing several gastrointestinal diseases. Fortunately, H. pylori infection is treatable, which can lower its comorbidities. However, data assessing physicians' awareness of H. pylori is lacking in Saudi Arabia.

Objective

To assess the knowledge and awareness of physicians of different specialties who practice in Saudi Arabia about H. pylori infection.

Methods

This is a cross-sectional study conducted between May and September 2022 on physicians across all regions in Saudi Arabia using a validated online questionnaire covering their knowledge and awareness of H. pylori infection. An independent t-test, one-way ANOVA, and Games-Howell as a post hoc test were used to analyze the data. A General Linear Model was also employed to determine significant predictors among the variables reliant on H. pylori awareness.

Results

The results showed that the mean awareness score of 474 physicians was 76.99± 6.9, indicating that participants had sufficient knowledge about H. pylori infection. In general, the internal medicine specialists (28.3%) had better awareness of H. pylori infection than the other specialties. Moreover, the university hospital sector performed the best, scoring 80.68±13.3, and the southern region had the highest-ranked physicians with a score of 81.56 ±13.7 in terms of H. pylori awareness. Furthermore, the general linear model revealed a statistical significance (p<0.05) for the following demographic aspects concerning H. pylori awareness: the physicians' age group of 30-39 years, duration of experience of 11-15 years, the hospital sectors of Nation Guards (NGH) and Security Forces (SFH), and the southern and central regions of practice in Saudi Arabia.

Conclusion

Physicians in Saudi Arabia have relatively sufficient awareness of H. pylori; however, they are highly influenced by age, years of experience, the hospital sector involved, and the region where the physicians practice.

The management of Helicobacter pylori infection and prevention and control of gastric cancer in China

Helicobacter pylori (H. pylori) infection, a type-1 carcinogen, was closely associated with gastric cancer (GC). Successfully eradicating H. pylori infection could reduce the incidence of GC. China was a country with high incidence of GC and high prevalence of H. pylori infection. Nearly half of worldwide GC new cases and deaths attributed to H. pylori infection occurred in China. H. pylori prevalence varied over time with the improvement of socioeconomic status and sanitary conditions. The knowledge of antibiotic resistance rate in time was important to guide the clinical choice of antibiotics use in the regimens. With the publication of five Chinese consensus reports on the management of H. pylori infection and the effort of public preach of H. pylori-related knowledge, the standardization of H. pylori diagnosis and treatment by clinicians was improved. Bismuth-containing quadruple therapy was widely applied in clinical practice of H. pylori eradication because of high efficacy and safety. High-dose Proton Pump Inhibitor-amoxicillin dual therapy or vonoprazan-amoxicillin dual therapy showed comparable efficacy and lower side effects than bismuth-containing quadruple therapy, which were the alternative choice. The diagnosis rate of early GC was low and distinguishing Chinese GC risk population for the further endoscopy screening was important. Efforts have been done to establish prediction models to stratify GC risk in the Chinese GC risk population. We reviewed the current situation of the management of H. pylori infection and prevention and control of GC in China here.

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.

Diagnosis and treatment of Helicobacter pylori infection by physicians in China: A nationwide cross-sectional study

BACKGROUND

To investigate the current state of knowledge and practice of Helicobacter pylori (H. pylori) infection management in China.

MATERIALS AND METHODS

This nationwide, multicenter, cross-sectional questionnaire survey was conducted between March and April 2021 with respect to the diagnosis and treatment of H. pylori infection in 31 provinces, encompassing over 1000 hospitals in mainland China. General physician information, diagnostic and detection status, eradication treatment, reexamination and follow-up after treatment, and basic knowledge of physicians were collected and compared with the Fifth Chinese National Consensus Report on Management of H. pylori infection and the 2016 Maastricht V/Florence guidelines. The subgroup analysis was also performed.

RESULTS

Of the 6873 questionnaire respondents, 48.8% were males, and 51.2% were females. Approximately, 26.5% of respondents indicated that their hospitals had dedicated clinics for managing H. pylori infection. Moreover, 88.0% of respondents prescribed a bismuth-containing quadruple regimen as the initial eradication treatment, and 92.7% deemed the gastric acid suppression critical. Furthermore, 91.0% of respondents routinely recommended a reexamination 1-2 months after eradication therapy, and 95.1% advised patients to stop PPI treatment at least 2 weeks before reexamination. The detail of following (the choice of target population/methods; the choice/availability of drugs/regimens, indications for eradication, factors influencing eradication efficacy/improvement methods and factors influencing adherence, management options/factors influencing relapse; the timing and methods, awareness of reinfection rates/prevention measures, and the approach to continuing education, awareness of guidelines, and acceptance of current core concepts of management) was also described. Subgroup analysis further revealed that significant differences were existed in being gastroenterologist or not, different education level, professional title, years of working, and provincial administrative regions.

CONCLUSIONS

Chinese physicians' skills and knowledge about the diagnosis and treatment of H. pylori infection could be improved. More works on education are needed in future.

Adherence to international guidelines for the management of Helicobacter pylori infection among gastroenterologists and gastroenterology fellows in Italy: A Survey of the Italian Federation of Digestive Diseases - FISMAD

BACKGROUND

Information on the management of Helicobacter (H.) pylori infection by gastroenterologists and gastroenterology fellows are scarce. We aimed to assess practice of gastroenterologists and gastroenterology fellows and their adherence to guidelines for diagnosis and treatment of H. pylori infection in Italy.

MATERIALS AND METHODS

All gastroenterologists and gastroenterology fellows attending the National Congress of Digestive Diseases - FISMAD were invited to fill-in an on-line questionnaire. The questionnaire included questions on the diagnosis and treatment of H. pylori infection.

RESULTS

A total of 279 gastroenterologists and 61 gastroenterology fellows participated to the study. The 13 C-urea breath test was the most preferred method among gastroenterologists and fellows for the diagnosis of H. pylori infection (40.4% and 57.6%, respectively) and the confirmation of eradication (61.3% and 70%, respectively). Sequential therapy was the most preferred first-line treatment of H. pylori for both gastroenterologists and gastroenterology fellows (31.8% and 44%, respectively), followed by bismuth quadruple therapy (31% and 27.6%, respectively) and clarithromycin triple therapy (26.8% and 22.4%, respectively). Only 30% of gastroenterologists and 38.5% of fellows used the clarithromycin triple therapy for the recommended duration of 14 days. Bismuth quadruple therapy was the most preferred second-line therapy for both gastroenterologists and fellows. The majority of gastroenterologists and fellows would prefer an empirical therapy at third line (72.6% and 62.5%, respectively) and a susceptibility-guided therapy at fourth line (46.7% and 71.4%, respectively).

CONCLUSIONS

Practices of gastroenterologists and gastroenterology fellows are in line with guidelines' recommendations, apart for the first-line treatment of H. pylori infection. Targeted educational interventions to improve adherence to guidelines are needed.

Gastric mucosa condition in patients with coronary artery disease and high risk of gastrointestinal bleeding (register REGATTA-1)

The key side effects of antiplatelet therapy are associated with the damage of the upper gastrointestinal tract (GIT) mucous that can lead to erosions or ulcers and specifically complicated by bleeding. Aim. To assess the upper gastrointestinal mucosal condition by endoscopic and histological methods in patients with stable coronary arteries disease receiving long-term antiplatelet therapy with gastrointestinal bleeding (GIB) history or with high risk of this complication. Materials and methods.The study included patients from the single-center prospective registry of long-term antithrombotic therapy REGATTA-1. The gastric mucosa endoscopic examination with biopsy was performed in 20 patients with gastrointestinal bleeding history less than 1 year ago and in 24 patients without GIB, which have concomitant risk factors such as erosions and ulcers history and/or persistent dyspepsia clinical signs. The mucosal condition (erosions and ulcers) was estimated using a modified Lanz scale. The presence of Helicobacter pylori was determined by Histological verification. The inflammatory process characteristics were evaluated according to the modified Sydney classification. All participants received antithrombotic therapy at the time of esophagogastroduodenoscopy; 81.8% of patients received proton pump inhibitors. Results. Chronic inflammation (93.2%), atrophy (59.1%), multiple erosions (45.5%) or ulcers (18.2%) were the most frequent endoscopic finding. H. pylori infection, found in mucosal samples in 90.9% of patients was one of the most important pathogenesis mechanism, which support the gastrointestinal mucosa damage. Conclusion. Mucosal damage endoscopic signs remains despite long-term proton pump inhibitors therapy in patients with coronary arteries disease and concomitant GIB risk factors, receiving antithrombotic therapy. H. pylori contamination may be the cause of these changes. Тtherefore, its active screening and eradication is necessary in such patients.

Empirical or susceptibility-guided treatment for Helicobacter pylori infection? A comprehensive review

Although susceptibility-guided therapy is frequently recommended for Helicobacter pylori infection, the evidence available to date supporting this strategy is limited. The aim of the present article is to review the advantages and limitations of the susceptibility-guided and the empirical strategies to treat this infection. We performed a bibliographic search to identify studies investigating H. pylori susceptibility-guided therapy. Culture is not the only way to assess antibiotic resistance, as different polymerase chain reaction-based approaches have been developed as alternative methods. For detecting H. pylori antimicrobial resistance, a molecular approach based on a stool sample might enable more convenient, time-saving methods. Unfortunately, the antimicrobial susceptibility cannot be obtained in all cases. Furthermore, antibiotic susceptibility testing in clinical practice yields useful information only for a few antibiotics: clarithromycin, metronidazole, and quinolones. In addition, susceptibility towards clarithromycin and metronidazole in vitro does not necessarily lead to eradication in vivo. In the case of H. pylori therapy failure, we should not re-administer any of the antibiotics against which H. pylori has probably become resistant. Our updated meta-analysis showed that susceptibility-guided treatment is not better than empirical treatment of H. pylori infection in first-line therapy if the most updated quadruple regimens are empirically prescribed, and similar efficacy results were also demonstrated with the two strategies for second-line therapy. Cumulative H. pylori eradication rate with several successive rescue therapies empirically prescribed reaches almost 100%. Finally, the studies that have evaluated the cost-effectiveness of the susceptibility-guided treatment have achieved contradictory results. In summary, we can conclude that the evidence is too limited to support the generalized use of susceptibility-guided therapy for H. pylori treatment in routine clinical practice, either as first-line or as rescue treatment. Nevertheless, it would be recommended that susceptibility tests are performed routinely, even before prescribing first-line treatment, in specialized centers with an interest in H. pylori management.

Helicobacter pylori Eradication in Patients Undergoing Gastrectomy: Diagnosis and Therapy

The role of <i>Helicobacter pylori</i> (<i>H. pylori</i>) eradication in patients undergoing gastrectomy for gastric cancer is unclear. Although European and Asian guidelines strongly recommend <i>H. pylori</i> eradication in patients who undergo endoscopic resection for early gastric cancer, these guidelines do not specify the tests useful for diagnosing <i>H. pylori</i> infection, the optimal timing and appropriate eradication regimens, and follow-up strategies in patients undergoing gastrectomy for gastric cancer. This review aims to update the guidelines for the diagnosis and management of <i>H. pylori</i> infection in patients undergoing gastrectomy for gastric cancer. We have focused on the following issues: 1) diagnostic tests for <i>H. pylori</i> infection in the remnant stomach, 2) optimal timing and regimen for <i>H. pylori</i> eradication, and 3) role of <i>H. pylori</i> eradication in reducing the risk of metachronous gastric cancer in the remnant stomach.