European Registry on the management of Helicobacter pylori infection (Hp-EuReg protocol): The first results of Russian centers

Self-Correcting Method for Highly Effective Office-Based Helicobacter pylori Therapy Using Cumulative Test of Cure Data

BACKGROUND AND AIM

Helicobacter pylori infections have become resistant to many previously highly effective antimicrobial regimens resulting in clarithromycin, metronidazole, or fluoroquinolone-containing therapies becoming unsuccessful. Pretreatment susceptibility testing is only widely available in the United States but is still rarely done. Here, we propose a framework to monitor H. pylori eradication in small clinical settings by routinely assessing the effectiveness of therapy.

METHODS

Because of the small sample size in individual practice's, we assume an acceptable cure rate of ≥80% (preferred cure rate ≥85%) in adherent patients, with a dichotomous outcome (cured vs. failed) and consecutive patient enrollment. To obtain results (feedback) in a timely manner, for individual practices, cure rates can be estimated after 10 patients. Large practices which acquire patients more rapidly can delay analysis until a total of 104 H. pylori-infected patients, assuming a baseline cure rate of at least 85% with the preferred regimen.

RESULTS

We show how data from individual practices can be utilized to improve the effectiveness of H. pylori treatment decisions. The method consists of recording and accumulating the confirmation of cure data for successive small groups of patients. These data are then analyzed as binary outcomes (pass-fail) and serve as the basis for studying and improving the effectiveness of H. pylori treatment decisions.

CONCLUSION

A simple actuarial method can serve outpatient clinics to ensure a reliable test-to-cure method and avoid futile Hp regimens.

Role of H.pylori in Chronic Sore Throat by Using H.pylori Line

Pharyngitis is an inflammation of the mucous membranes of the oropharynx. Pharyngitis may be caused by an infectious or noninfectious disease. Noninfectious diseases of pharynx include allergies, trauma, cancer, reflux and certain toxins. Infection with H. Pylori is associated with developing chronic sore throat, gastritis, gastric or duodenal ulcer, gastric cancer and MALT lymphoma. There are many different investigations to diagnose H pylori as H pylori antigen in blood and stool, urea breath test but, H. Pylori line is a new test for detection of the virulent strains. There are many lines of H pylori therapy in the form of PPIs and antibiotics for about two weeks. This study aimed to detect role of H pylori in chronic pharyngitis. 85 patients who had chronic pharyngitis with normal CBC, WBCS, lymphocyte, monocyte and eosinophils with negative ASO titer and throat swab. These patients did H pylori line to detect H pylori virulent antigen. 77 patients with chronic pharyngitis are positive H pylori and after medical treatment 68 patients became negative. H. Pylori line is a new test for detection of the virulent strains and screening H pylori carrier at risk of developing gastric and duodenal ulcers as well as cancer.

Gastric cancer in a patient with chronic gastritis after <i>H. pylori</i> eradication: assessing the risks

Stomach cancer occupies a leading position in oncological morbidity and mortality worldwide. Approximately 800,000 people die from stomach cancer every year. In two-thirds of patients gastric cancer is diagnosed at a late stage, when radical treatment becomes impossible. Helicobacter pylori (H. pylori) infection is considered as the main etiological factor for gastric cancer. To stratify the risk of developing gastric cancer an assessment of morphological changes in the gastric mucosa using the Operative Link for Gastritis Assessment of Atrophic Gastritis (OLGA) system is used. The stage of gastritis plays a key role in determining an individual’s risk of developing stomach cancer. H. pylori eradication therapy is an effective method for preventing gastric cancer. However not in all patients the elimination of the infection can prevent the development of gastric cancer in the future. It is extremely important to identify a group of people with ex-helicobacter gastritis, who have a high risk of developing stomach cancer, and to take timely preventive measures in them. The purpose of this publication is to summarize and systematize the currently available data on the risk of developing gastric cancer in patients with H. pylori-associated gastritis, including those after successful eradication.

Randomised clinical trial: comparison of efficacy and adverse effects of a standard triple clarithromycin-containing regimen with high-dose amoxicillin and bismuth therapy in Helicobacter pylori eradication

BACKGROUND

The clarithromycin-based triple therapy is the most prescribed Helicobacter pylori eradication regimen in Europe; it causes adverse effects in a significant proportion of subjects, leading to discontinuation. Alternative therapies are required because of increasing clarithromycin resistance or to decrease the adverse effects.

AIMS

We compared the efficacy and spectrum of adverse effects of clarithromycin-based triple therapy with the high-dose amoxicillin/bismuth regimen.

METHODS

A randomised clinical trial enrolled healthy individuals aged 40-64 years. H. pylori was assessed with a 13C-urea breath test. In total 579 H. pylori-positive subjects were randomly allocated in two groups: group 1: clarithromycin 500 mg, amoxicillin 1000 mg, esomeprazole 40 mg, all twice daily; group 2: bismuth subcitrate 240 mg twice daily, amoxicillin 1000 mg three times daily, esomeprazole 40 mg twice daily. Regimens were administered for 14 days.Information on treatment completion and adverse effects were collected via a telephone interview at 21-28 days after medication delivery. The efficacy was assessed by UBT 6 months after the treatment.

RESULTS

We analysed 483 subjects for adverse effects (248 vs. 235 respectively). Furthermore, 316 subjects were analysed for efficacy. In per-protocol analysis, a higher efficacy was seen in group 1 (88.4 vs. 77.0%; P < 0.001); no difference was observed in compliance (90.3 and 91.2%). Therapy-related adverse effects were more common in group 1 (56.9 vs. 40.0%; P < 0.01). In intention-to-treat analysis no statistical difference in efficacy was revealed.

CONCLUSIONS

Bismuth-based high-dose amoxicillin therapy showed a lower efficacy but was less frequently associated with adverse effects. Further research is required to examine the high-dose amoxicillin and bismuth-containing regimens in various populations to maximise eradication efficacy.

Errors in the diagnosis and treatment of <i>Helicobacter pylori</i> infection: in anticipation of new conciliation documents

The high prevalence of H. pylori and diseases caused by this infection determine the relevance of discussing the problems of its diagnosis and treatment on the eve of the emergence of new international and domestic agreements. Studies published in recent years, including articles on the materials of the European Registry on the management of Helicobacter pylori infection (Hp-EuReg), provide a rich background for the analysis of errors in diagnosis and treatment of this infection, and the development of approaches to optimize clinical practice.

Errors in the diagnosis and treatment of <i>Helicobacter pylori</i> infection: in anticipation of new conciliation documents

The high prevalence of H. pylori and diseases caused by this infection determine the relevance of discussing the problems of its diagnosis and treatment on the eve of the emergence of new international and domestic agreements. Studies published in recent years, including articles on the materials of the European Registry on the management of Helicobacter pylori infection (Hp-EuReg), provide a rich background for the analysis of errors in diagnosis and treatment of this infection, and the development of approaches to optimize clinical practice.

[European Registry on the management of Helicobacter pylori infection: features of diagnosis and treatment in Kazan]

BACKGROUND

As part of an observational multicenter prospective study European Registry on the management of Helicobacter pylori infection, conducted on the initiative of the European H. pylori and Microbiota Study Group, the compliance of clinical practice in the management of patients with Helicobacter pylori infection in Kazan with clinical guidelines was assessed.

MATERIALS AND METHODS

The data of 437 patients included into the register by clinical sites in Kazan in 20132019 were analyzed. The methods used for the initial diagnosis of H. pylori infection and eradication control were evaluated. The frequency of various eradication therapy regimens prescription was analyzed in 379 cases. Data regarding the effectiveness of eradication therapy was analyzed in 173 patients.

RESULTS

The rapid urease test (44.2% of cases) and cytology/histology (60% of cases) were most often used for the initial diagnosis of H. pylori infection; however non-invasive methods such as 13C-urea breath (9.2%), serology (6.2%), H. pylori stool antigen test (2.3%) were less common. In 21.7% of patients two methods of H. pylori detection were used for primary diagnosis. The control test to evaluate the effectiveness of eradication therapy at the recommended timepoint was performed in 46.2% of patients. 13C-urea breath test (31.7%), stool PCR/stool antigen test (28.7%), rapid urease test (22.3%), cytology/histology (26.2% of cases) prevailed in the assessment of eradication rate. Standard triple therapy, including proton pump inhibitor, clarithromycin and amoxicillin was most commonly prescribed as first-line therapy (64.6% of cases). The duration of eradication therapy was 14 days in the majority of cases with pantoprazole as the most common proton pump inhibitor in standard triple therapy regimens (84.8%). The efficacy of 14-day standard triple therapy (mITT) was 87.0%.

CONCLUSION

The results indicate a high frequency of non-invasive methods use for assessing the effectiveness of eradication therapy; however, the overall rate of eradication efficacy assessment is low, limiting the possibility of analyzing the eradication results. The effectiveness of the most common 14-day standard triple first-line therapy in Kazan doesnt reach the recommended 90% eradication level. This could be explained by high rate of pantoprazole use, which is not an optimal proton pump inhibitor in eradication therapy regimens.

Update on the Management of Helicobacter pylori Infection

Purpose of review

Our purpose was to provide an update on methods and indications for testing and treatment selection focusing on novel modalities.

Recent findings

Increasing antibiotic resistance has reduced treatment effectiveness. Antibiotic resistance testing is not widely available in North America where there are insufficient resistance and susceptibility data. Quadruple regimens (bismuth-based or concomitant/non-bismuth-based) have been recommended first-line. A rifabutin-based combination product recently approved by the US Food and Drug Administration is highly effective and should simplify treatment. The potassium-competitive acid blocker vonoprazan is being evaluated as part of dual or triple combination regimens. Molecular-based genotypic testing for antibiotic resistance and an effective H. pylori vaccine remain under development.

Summary

Inability to test for antibiotic resistance renders treatment selection empiric. However, resistance to rifabutin and amoxicillin remains rare. Effective management continues to comprise appropriate diagnostic testing for active infection, utilization of an effective regimen, and post-treatment testing.

European registry on Helicobacter pylori management (Hp-EuReg) as a tool to evaluate and improve clinical practice in Moscow

Continuous evaluation of the actual clinical practice of diagnosis and treatment of Helicobacter pylori is crucial in order to provide the best standard of care and to compare health outcomes with expert recommendations. Aim:to evaluate the effectiveness of the standard triple therapy (amoxicillin, clarithromycin, a proton pump inhibitor) and the standard triple therapy plus bismuth tripotassium dicitrate. Materials and methods.Observational, prospective, multicenter study, carried out in one single Russian centre A.S. Loginov Moscow Clinical Scientific Center as part of the Hp-EuReg. Patients were included from 2013 to November 2019 by Russian gastroenterologists. Results.A total of 647 patients were collected and 330 were administered either standard triple therapy ((amoxicillin, clarithromycin, a proton pump inhibitor) or standard triple therapy plus bismuth tripotassium dicitrate. Invasive methods is dominates in the initial diagnosis of H. pylori: the frequency of use of the quick urease test decreased from 50% in 2013 to 31% in 2019. Serology was used in 27.9%. There has been an increase in the use of the13C-urea breath test from 13% in 2013 to 31% in 2019. The histological method (7.5%) and the stool antigen test (3.2%) were used less frequently. For eradication control non-invasive methods are mostly used:13C-UDT (82.7%) and the stool antigen test (14.4%). The effectiveness of standard triple therapy (mITT) was 68% with a 7-day course, 79% with a 10-day course, and 70% with a 14-day course. Combination of bismuth and standard triple therapy eradicates H. pylori (mITT) in 63%, 75% and 89%, respectively. Conclusion.An improvement in the clinical practice of managing patients with H. pylori infections has been noted. The standard triple therapy in combination with bismuth tripotassium dicitrate, prescribed for 14 days, is more effective.

Efficacy of H. pylori eradication depending on genetic polymorphism of CYP2C19, MDR1 and IL-1β

Aim. To evaluate an association of genetic polymorphisms CYP2C19, MDR1, and IL-1β on the eradication rate by 10-day modified therapy in patients with H. pylori - associated diseases. Materials and methods. In this study was conducted a prospective, randomized trial, included 89 patients with H. pylori - associated diseases. They were divided into 2 groups depending on therapy: clarithromycin 500 mg, b.i.d., amoxicillin 1000 mg, b.i.d., bismuth subcitrate 240 mg, b.i.d. rabeprazole 20 mg or 40 mg, b.i.d. for 10 days. All subjects underwent pharmacogenetic testing of CYP2C19, MDR1, and IL-1β. Results and discussion. Per - protocol (PP) eradication rates in group with rabeprazole 40 mg were 97.6% (41/42; 95% CI 87.7-99.6), in group with rabeprazole 20 mg were 82.1% (32/39; 95% CI 67.3-91.0). Intention - to - treat analysis in group with rabeprazole 40 mg eradication rates were 89.1% (41/46; 95% CI 77.0-95.3), in group with standard dose rabeprazole - 74.4% (32/43; 95% CI 59.8-85.1). No significant differences in eradication rates between the groups of ultrarapid, rapid, normal and intermediate CYP2C19 metabolizers (PP: 93.5%/90.3%/84.6% respectively; χ2=0.87, p=0.65). Eradication rates in group with IL-1β CC genotype there was no difference among the IL-1β CT and TT genotype groups (PP: 92.9%/85.7%/94.7% respectively; χ2=1.34; p=0.51). The cure rate among MDR1 TT genotype was significantly lower than among subjects in the MDR1 CC/CT genotype groups (PP: 76.2% vs 96.3%: χ2=5.04; p=0.025; OR=8.13). Conclusion. Ten - day modified triple therapy with high dose rabeprazole significantly high eradication rates in patients with H. pylori - associated diseases. Independent factor for treatment failure is MDR1 CC/CT genotype status.

Diagnosis of Helicobacter pylori infection in clinical practice

Diagnostic tests used to detection Helicobacter pylori are divided into invasive (requiring endoscopy) and non-invasive, direct (bacteriological, histological or molecular detection of the bacterium) and indirect (detection of urease activity of the bacterium or antibodies to it). The choice of the test is determined by the clinical situation, as well as by its availability and cost. The sensitivity of most tests is affected by the use of antisecretory drugs and antibiotics.

[European registry Helicobacter pylori (Hp-EuReg): how has clinical practice changed in Russia from 2013 to 2018 years]

The multicenter prospective observational study initiated by the European Helicobacter and Microbiota Study Group (EHMSG) is conducted in 27 countries in Europe. The data from the Russian part of the European registry for the management of Helicobacter pylori infection (European Registry on the management of Helicobacter pylori infection, protocol: "Hp-EuReg") allows us to analyze the real clinical practice of diagnosis and treatment of H. pylori and compare it with international recommendations.

MATERIALS AND METHODS

A comparative analysis of the data entered in the register by the Russian research centers "Hp-EuReg", in the period from 2013 to 2018, was conducted.

RESULTS AND DISCUSSION

Invasive diagnostic methods prevail for the primary diagnosis of H. pylori [histology - 20.3% (in 2013 year) - 43.9% (in 2018 year), rapid urease test - 31.7% and 47.8% respectively]. The most popular mode of eradication therapy is a 10-day triple therapy (62.8-76.2%), the effectiveness of which does not exceed 79% (per protocol). Invasive tests (histology) are the leading method for control the effectiveness of therapy, however, there is a tendency towards a wider use of non-invasive methods (H. pylori stool antigen - from 17% in 2013 to 29.3% in 2018 and urea breath test from 6.9 to 18.3%, respectively). Serological test to control the effectiveness of eradication is still used from 8.2% (2013) to 6.1% (2018). Eradication therapy was not performed in 28% of patients throughout the entire observation period.

CONCLUSION

In Russia, despite approved domestic and international recommendations, deviations in clinical practice persist, both during eradication therapy and in monitoring the effectiveness of eradication therapy.