Optimal initiation of Helicobacter pylori eradication in patients with peptic ulcer bleeding

V Spanish Consensus Conference on Helicobacter pylori infection treatment

Helicobacter pylori infection is very common in the Spanish population and represents the main cause of chronic gastritis, peptic ulcer, and gastric cancer. The last iteration of Spanish consensus guidelines on H. pylori infection was conducted in 2016. Recent changes in therapeutic schemes along with increasing supporting evidence were key for developing the V Spanish Consensus Conference (May 2021). Fourteen experts performed a systematic review of the scientific evidence and developed a series of recommendations that were subjected to an anonymous Delphi process of iterative voting. Scientific evidence and the strength of the recommendation were classified using GRADE guidelines. An eradication therapy, when prescribed empirically, is considered acceptable when it reliably achieves, or preferably surpass, 90% cure rates. Currently, only quadruple therapies (with or without bismuth) and generally lasting 14 days, accomplish this goal in first- and second-line therapies. A non-bismuth quadruple concomitant regimen (proton pump inhibitor, clarithromycin, amoxicillin, and metronidazole) or a quadruple bismuth-based combination (proton pump inhibitor, bismuth, tetracycline, and metronidazole), are recommended as first-line regimens. Rescue therapies after eradication failure and management of H. pylori infection in peptic ulcer disease were also reviewed.

A standardized protocol improves testing rates for Helicobacter Pylori among inpatients with peptic ulcer disease

BACKGROUND

Despite a strong link between Helicobacter Pylori infection and peptic ulcer disease (PUD), rates of testing for H. Pylori in hospitalized patients with PUD remain largely unexplored. We aimed to determine H. Pylori testing practices at our institution among inpatients with PUD, and to implement a protocol to improve testing rates.

MATERIALS AND METHODS

In this quality improvement initiative, baseline H. Pylori testing practices were determined by analysis of historical data on 100 subsequent inpatients with PUD from January 2016 to June 2017 at a tertiary care hospital undergoing esophagogastroduodenoscopy (EGD). Subsequently, a division-wide testing protocol was implemented, and data were analyzed from 43 consecutive inpatients with PUD from October 2019-March 2020 to determine the protocol's effects.

RESULTS

The analysis of baseline testing practices showed a 57% testing rate for H. Pylori. Gastric biopsies were less likely to be performed during EGDs done outside the endoscopy unit (5.9% vs 32.7%, P = 0.001), outside of usual business hours (6.7% vs 24.3%, P = 0.04), and in cases where endoscopic therapy was administered (6% vs 32%, P = 0.02). After implementation of the new division-wide testing protocol, testing rates increased to 93% (P < 0.001).

CONCLUSIONS

Low baseline inpatient testing for H. Pylori represents a missed opportunity to test a substantial number of high-risk patients with PUD. Implementation of a conceptually simple protocol aimed at increasing rates of gastric biopsy significantly improved testing rates in a prospective follow-up. Widespread standardization of H. Pylori testing for inpatients with PUD may improve important patient outcomes related to complicated PUD.

Low Rates of Retesting for Eradication of Helicobacter pylori Infection After Treatment in the Veterans Health Administration

BACKGROUND & AIMS

Expert consensus mandates retesting for eradication of Helicobacter pylori infection after treatment, but it is not clear how many patients are actually retested. We evaluated factors associated with retesting for H pylori in a large, nationwide cohort.

METHODS

We performed a retrospective cohort study of patients with H pylori infection (detected by urea breath test, stool antigen, or pathology) who were prescribed an eradication regimen from January 1, 1994 through December 31, 2018 within the Veterans Health Administration (VHA). We collected data on demographic features, smoking history, socioeconomic status, facility poverty level and academic status, and provider specialties and professions. The primary outcome was retesting for eradication. Statistical analyses included mixed-effects logistic regression.

RESULTS

Of 27,185 patients prescribed an H pylori eradication regimen, 6486 patients (23.9%) were retested. Among 7623 patients for whom we could identify the provider who ordered the test, 2663 patients (34.9%) received the order from a gastroenterological provider. Female sex (odds ratio, 1.22; 95% CI, 1.08-1.38; P = .002) and history of smoking (odds ratio, 1.24; 95% CI, 1.15-1.33; P < .001) were patient factors associated with retesting. There was an interaction between method of initial diagnosis of H pylori infection and provider who ordered the initial test (P < .001). There was significant variation in rates of retesting among VHA facilities (P < .001).

CONCLUSIONS

In an analysis of data from a VHA cohort of patients with H pylori infection, we found low rates of retesting after eradication treatment. There is significant variation in rates of retesting among VHA facilities. H pylori testing is ordered by nongastroenterology specialists two-thirds of the time. Confirming eradication of H pylori is mandatory and widespread quality assurance protocols are needed.

Accuracy of the Helicobacter pylori diagnostic tests in patients with peptic ulcer bleeding: a systematic review and network meta-analysis

INTRODUCTION

Some studies suggest that the accuracy of Helicobacter pylori diagnostic tests is decreased in peptic ulcer bleeding (PUB). We aimed to assess the accuracy of diagnostic tests for H. pylori in patients with PUB in a diagnostic test accuracy (DTA) network meta-analysis.

METHODS

A systematic search was carried out in seven databases until November 2019. We collected or calculated true and false positive and negative values, and constructed 2×2 diagnostic contingency tables with reference standards including histology, rapid urease test, urea breath test, serology, stool antigen test, culture, and polymerase chain reaction. We ranked the index tests by the superiority indices (SI) and calculated pooled sensitivity and specificity of each test.

DISCUSSION

Our search yielded 40 eligible studies with 27 different diagnostic strategies for H. pylori. In 32 articles, the reference standard was a combination of multiple tests. In 12 studies, the index tests were compared with a single testing method. We analyzed seven networks with the reference standards against a single or a combination of diagnostic index tests. None of the index tests had better diagnostic accuracy (SI between 9.94 and 2.17) compared with the individual index tests as all the confidence intervals included 1. Combined testing strategies had higher sensitivities (0.92-0.62) and lower specificities (0.85-0.46) while single tests proved to have higher specificities (0.83-0.77) and lower sensitivities (0.73-0.42).

CONCLUSION

Use of combined tests may have a rationale in clinical practice due to their higher sensitivities. The differences between the included DTA studies limited the comparison of the testing strategies.

Perforated and bleeding peptic ulcer: WSES guidelines

Background

Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment.

Methods

The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached.

Conclusions

The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Helicobacter pylori-associated peptic ulcer disease: A retrospective analysis of post-treatment testing practices

BACKGROUND & AIMS

Guidelines recommend that patients with Helicobacter pylori (H. pylori)-associated peptic ulcer disease (PUD) receive H. pylori eradication therapy followed by post-treatment testing to prove eradication; however, post-treatment testing rates are suboptimal and barriers to testing are poorly understood. Our aim was to identify factors that predicted receipt of post-treatment testing.

METHODS

We performed a retrospective cohort study of 152 patients with H. pylori-associated PUD diagnosed between 2007 and 2015 at a large tertiary medical center in the United States, who received standard eradication therapy and ambulatory follow-up within one year. The primary outcome of interest was receipt of post-treatment testing. Logistic regression models compared post-treatment testing rates in those diagnosed while outpatient vs inpatient, patients with vs without repeat endoscopy, and patients with vs without gastroenterology (GI) clinic follow-up. Propensity scores controlled for age, sex, race, ulcer location, and symptom persistence.

RESULTS

Among 152 patients, 67 (44%) patients received post-treatment testing. There were significant differences in post-treatment testing rates in those diagnosed as outpatients vs inpatients (57% vs 33%; OR 3.87, P = 0.001) and in patients with vs without GI follow-up (62% vs 11%; OR 9.85, P < 0.0001).

CONCLUSIONS

The rate of testing for eradication after treatment in patients with H. pylori- associated PUD was low. However, this was significantly improved in patients who have GI follow-up and whose diagnosis was made in the outpatient setting. Our study demonstrates a clear opportunity for quality improvement initiatives.

Early Diagnosis of Helicobacter pylori Infection in Vietnamese Patients with Acute Peptic Ulcer Bleeding: A Prospective Study

Aims. To investigate H. pylori infection rate and evaluate a combined set of tests for H. pylori diagnosis in Vietnamese patients with acute peptic ulcer bleeding (PUD). Methods. Consecutive patients with acute PUB were enrolled prospectively. Rapid urease test (RUT) with 3 biopsies was carried out randomly. Patients without RUT or with negative RUT received urea breath test (UBT) and serological and urinary H. pylori antibody tests. H. pylori was considered positive if RUT or any noninvasive test was positive. Patients were divided into group A (RUT plus noninvasive tests) and group B (only noninvasive tests). Results. The overall H. pylori infection rate was 94.2% (161/171). Groups A and B had no differences in demographic characteristics, bleeding severity, endoscopic findings, and proton pump inhibitor use. H. pylori-positive rate in group A was significantly higher than that in group B (98.2% versus 86.7%, p = 0.004). The positive rate of RUT was similar at each biopsy site but significantly increased if RUT results from 2 or 3 sites were combined (p < 0.05). Conclusions. H. pylori infection rate in Vietnamese patients with acute PUB is high. RUT is an excellent test if at least 2 biopsies are taken.