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2017 ACG Guidelines for Peptic Ulcer Disease |
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Guidelines for the Indications to Test for, and to Treat, H. pylori Infection |
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Guidlines for factors that predict the successful eradication when treating H. pylori infection |
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Guidelines to document H. pylori antimicrobial resistance in the North America |
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Guidelines for evaluation and testing of H. pylori antibiotic resistance |
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Guidelines for when to test for treatment success after H. pylori eradication therapy |
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Guidelines for penicillin allergy in patients with H. pylori infection |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Antimicrobial agent is indicated for patients with gastric or duodenal peptic ulceration who are colonized with Helicobacter pylori and patients with MALT lymphoma. Eradication therapy should also be considered for patients with immune thrombocytopenic purpura who are H. pylori positive or patients who have undergone resection for early-stage gastric cancer. The use of antibiotics is discouraged in asymptomatic carriers.
Medical Therapy
- Younger patients with ulcer-like symptoms are often treated with antacids or H2 antagonists before EGD is undertaken.Bismuth compounds may actually reduce or even clear organisms.
- Patients who are taking nonsteroidal anti-inflammatories (NSAIDs) may also be prescribed a prostaglandin analogue (Misoprostol) in order to help prevent peptic ulcers, which may be a side-effect of the NSAIDs.
- When H. pylori infection is present, the most effective treatments are combinations of 2 antibiotics (e.g. Erythromycin,Ampicillin, Amoxicillin, Tetracycline, Metronidazole) and 1 proton pump inhibitor (PPI). An effective combination would be Amoxicillin + Metronidazole + Pantoprazole (a PPI). In the absence of H. pylori, long-term higher dose PPIs are often used.
- Treatment of H. pylori usually leads to clearing of infection, relief of symptoms and eventual healing of ulcers. Recurrence of infection can occur and retreatment may be required, if necessary with other antibiotics. Since the widespread use of PPI's in the 1990s, surgical procedures (like "highly selective vagotomy") for uncomplicated peptic ulcers became obsolete.
Principles of Eradication Therapy for Helicobacter pylori infection
The following table contains the indications for diagnosis and treatment of Helicobacter pylori infection[1]
| Indications for diagnosis and treatment of Helicobacter pylori infection |
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| Active peptic ulcer disease |
| Confirmed history of peptic ulcer disease not previously treated for H. pylori |
| Gastric MALT lymphoma |
| After endoscopic resection of early gastric cancer |
- Low clarithromycin resistance areas (<15%):[2]
- In areas of low resistance the PPI-clarithromycin-containing triple therapy is recommended as the first-line treatment as well as bismuth-containing quadruple therapy.
- In areas of low resistance after failure of a PPI-clarithromycin-containing treatment, either a bismuth-containing quadruple therapy or levofloxacin-containing triple therapy is recommended.
- High clarithromycin resistance areas (≥15%):[2]
- In areas of high resistance, bismuth-containing quadruple therapy is recommended as the first-line treatment.
- In areas of high resistance after failure of bismuth containing quadruple therapy, Levofloxacin containing triple therapy is recommended.
- If the second-line treatment fails, the antibiotic therapy should guided by antimicrobial susceptibility testing.[2]
- FDA approved first line regimens duration:[3]
- Triple therapy: 7 days (10 days if rabeprazole is used).
- Quadruple therapy: 4 weeks.
- Patients who have had a previous H. pylori associated ulcer or gastric MALT lymphoma or who have had surgical resection for early gastric cancer, confirmation tests for eradication of H. pylori infection should be done.[4]
- The best nonendoscopic test to confirm eradication of H. pylori infection is the urea breathing test.[3]
- Testing to prove H. pylori eradication is most accurate if performed 4 weeks after the completion of the therapy.[4]
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† There is a reported prevalence of 15% in the Northeast of the US.
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Eradication Therapy for Helicobacter pylori Infection
Regimens for initial treatment
- Proton pump inhibitor (standard dose twice daily) for 7–14 days AND
- Amoxicillin (1 g twice daily) for 7–14 days AND
- Clarithromycin (500 mg twice daily) for 7–14 days
- Proton pump inhibitor (standard dose twice daily) for 10–14 days AND
- Metronidazole (250 mg four times daily) for 10–14 days AND
- Tetracycline (500 mg four times daily) for 10–14 days AND
- Bismuth (dose depends on preparation) for 10–14 days
- Proton pump inhibitor (standard dose twice daily) for 5 days AND
- Amoxicillin (1 g twice times daily) for 5 daysFollowed by
- Proton pump inhibitor (standard dose twice daily) for another 5 days AND
- Clarithromycin (500 mg twice daily) for another 5 days AND
- Tinidazole (500 mg twice daily) for another 5 days
Second-line therapies
- Proton pump inhibitor (standard dose twice daily) for 7–14 days AND
- Amoxicillin (1 g twice daily) for 7–14 days AND
- Metronidazole (250 mg four times daily) for 7–14 days
- Proton pump inhibitor (standard dose twice daily) for 10 days AND
- Amoxicillin (1 g twice daily) for 10 days AND
- Levofloxacin (500 mg twice daily) for 10 days
- Proton pump inhibitor (standard dose twice daily) for 10 days AND
- Amoxicillin (1 g twice daily) for 10 days AND
- Rifabutin (150–300 mg/day) for 10 days
Contraindicated Medications
Bleeding peptic ulcer is considered an absolute contraindication to the use of the following medications:
Guidelines and Resources
- American College of Gastroenterology (ACG) – Guidelines for the management of dyspepsia.[9]
- American Society for Gastrointestinal Endoscopy (ASGE) – The role of endoscopy in dyspepsia.[10]
- American Society for Gastrointestinal Endoscopy (ASGE) – The role of endoscopy in gastroduodenal obstruction and gastroparesis.[11]
- American College of Cardiology Foundation/American College of Gastroenterology/American Heart Association (ACCF/ACG/AHA) – Reducing the gastrointestinal risks of antiplatelet therapy and NSAID use.[12]
References
- ↑ Koperna T, Schulz F (1996). "Prognosis and treatment of peritonitis. Do we need new scoring systems?". Arch Surg. 131 (2): 180–6. PMID 8611076.
- ↑ 2.0 2.1 2.2 Malfertheiner P, Megraud F, O'Morain CA, Atherton J, Axon AT, Bazzoli F; et al. (2012). "Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report". Gut. 61 (5): 646–64. doi:10.1136/gutjnl-2012-302084. PMID 22491499.
- ↑ 3.0 3.1 Chey WD, Wong BC, Practice Parameters Committee of the American College of Gastroenterology (2007). "American College of Gastroenterology guideline on the management of Helicobacter pylori infection". Am J Gastroenterol. 102 (8): 1808–25. doi:10.1111/j.1572-0241.2007.01393.x. PMID 17608775.
- ↑ 4.0 4.1 McColl KE (2010). "Clinical practice. Helicobacter pylori infection". N Engl J Med. 362 (17): 1597–604. doi:10.1056/NEJMcp1001110. PMID 20427808.
- ↑ 5.0 5.1 Mégraud F (2004). "H pylori antibiotic resistance: prevalence, importance, and advances in testing". Gut. 53 (9): 1374–84. doi:10.1136/gut.2003.022111. PMC 1774187. PMID 15306603.
- ↑ 6.0 6.1 Duck WM, Sobel J, Pruckler JM, Song Q, Swerdlow D, Friedman C; et al. (2004). "Antimicrobial resistance incidence and risk factors among Helicobacter pylori-infected persons, United States". Emerg Infect Dis. 10 (6): 1088–94. doi:10.3201/eid1006.030744. PMC 3323181. PMID 15207062.
- ↑ 7.0 7.1 De Francesco V, Giorgio F, Hassan C, Manes G, Vannella L, Panella C; et al. (2010). "Worldwide H. pylori antibiotic resistance: a systematic review". J Gastrointestin Liver Dis. 19 (4): 409–14. PMID 21188333.
- ↑ 8.0 8.1 Boyanova L, Mitov I (2010). "Geographic map and evolution of primary Helicobacter pylori resistance to antibacterial agents". Expert Rev Anti Infect Ther. 8 (1): 59–70. doi:10.1586/eri.09.113. PMID 20014902.
- ↑ Talley, Nicholas J.; Vakil, Nimish; Practice Parameters Committee of the American College of Gastroenterology (2005-10). "Guidelines for the management of dyspepsia". The American Journal of Gastroenterology. 100 (10): 2324–2337. doi:10.1111/j.1572-0241.2005.00225.x. ISSN 0002-9270. PMID 16181387. Check date values in:
|date=(help) - ↑ Ikenberry, Steven O.; Harrison, M. Edwyn; Lichtenstein, David; Dominitz, Jason A.; Anderson, Michelle A.; Jagannath, Sanjay B.; Banerjee, Subhas; Cash, Brooks D.; Fanelli, Robert D.; Gan, Seng-Ian; Shen, Bo; Van Guilder, Trina; Lee, Kenneth K.; Baron, Todd H.; ASGE STANDARDS OF PRACTICE COMMITTEE (2007-12). "The role of endoscopy in dyspepsia". Gastrointestinal Endoscopy. 66 (6): 1071–1075. doi:10.1016/j.gie.2007.07.007. ISSN 0016-5107. PMID 18028927. Check date values in:
|date=(help) - ↑ ASGE Standards of Practice Committee; Fukami, Norio; Anderson, Michelle A.; Khan, Khalid; Harrison, M. Edwyn; Appalaneni, Vasudhara; Ben-Menachem, Tamir; Decker, G. Anton; Fanelli, Robert D.; Fisher, Laurel; Ikenberry, Steven O.; Jain, Rajeev; Jue, Terry L.; Krinsky, Mary Lee; Maple, John T.; Sharaf, Ravi N.; Dominitz, Jason A. (2011-07). "The role of endoscopy in gastroduodenal obstruction and gastroparesis". Gastrointestinal Endoscopy. 74 (1): 13–21. doi:10.1016/j.gie.2010.12.003. ISSN 1097-6779. PMID 21704805. Check date values in:
|date=(help) - ↑ Bhatt, Deepak L.; Scheiman, James; Abraham, Neena S.; Antman, Elliott M.; Chan, Francis K. L.; Furberg, Curt D.; Johnson, David A.; Mahaffey, Kenneth W.; Quigley, Eamonn M.; American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (2008-10-28). "ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents". Circulation. 118 (18): 1894–1909. doi:10.1161/CIRCULATIONAHA.108.191087. ISSN 1524-4539. PMID 18836135.