Helicobacter pylori (H. pylori) is an infectious disease occurring in the stomach that causes dyspepsia, peptic ulcer disease, and gastric cancer. Globally it is one of the most common chronic bacterial infections and the leading cause of infection-associated cancer.
Infection with H. pylori is usually acquired early in life. Socioeconomic status during childhood is a strong determinant of chronic H. pylori infection with people from lower socioeconomic backgrounds being more frequently affected.
In this Guidelines Side-by-Side, we have compared the latest clinical practice guidelines from the American College of Gastroenterology (ACG) and the World Gastroenterology Organisation (WGO) on H. pylori. The recommendations made are meant to guide clinical practice, taking into consideration the unique desires and needs of individual patients.
Guidelines for Comparison
| Authoring Organization | American College of Gastroenterology (ACG) | World Gastroenterology Organisation (WGO) |
| Publication Date | September 2024 | April 2021 |
| Graded Recommendations | Yes | No |
| Uses GRADE | Yes | No |
| Links | Summary Full Text | Summary Full Text |
Key Takeaways
- The ACG guideline provides key concepts and graded recommendations for testing, treatment, and management of H. pylori aimed at patients in North America. In contrast WGO gives key statements and good practice points for testing and management of H. pylori on a more global scale. While the WGO guideline does not offer specific graded treatment recommendations, it does review data on first-line, second-line, and salvage therapy for H. pylori, taking into consideration regional resources and clarithromycin resistance rates.
- Both Guidelines agree that testing for H. pylori disease and antimicrobial resistance are important for treatment and eradication. The WGO recognizes under-resourced regions and suggests that polymerase chain reaction (PCR) may be utilized as an inexpensive rapid test to both diagnose H. pylori and assess antimicrobial resistance.
- The importance of determining clarithromycin resistance before beginning treatment is also emphasized in both guidelines.
Comparison of Recommendations
| Topic | ACG | WGO |
|---|---|---|
| Epidemiology | Key concept: The prevalence of H. pylori infection in North America is decreasing over time but remains substantial at 30%–40%. The infection is typically acquired in childhood and is more prevalent among non-White races and ethnicities, those living in crowded or poor sanitary conditions, and early generation immigrants from countries where H. pylori is endemic. | Key statement: It is a major challenge for guidelines to achieve relevance across a wide variety of populations with varying spectrums of disease and with vastly different resources with which to deal with it. |
| Key statement: The major determinant of the prevalence of infection is socioeconomic status in childhood. | ||
| Key statement: As with most endemic infectious diseases, a decline in prevalence has more to do with improvements in population hygiene and sanitation than with individual, case-by-case treatment, since in most countries, only a minority of infected individuals will ever receive therapy. | ||
| Testing and Decision to Treat | Key concept: The determination of when to test for—and treat—H. pylori should be viewed as a single, rather than 2 separate and distinct, decisions. | Good practice point: The decision to test for H. pylori should only be made with therapeutic intent. |
| Key statement: Eradication of H. pylori before the occurrence of adverse, precancerous histological changes has been shown to prevent gastric cancer and is the rationale for mass test-and-treat screening programs in young adults in countries with a high burden of disease and with sufficient resources to devote to this endeavor. | ||
| Key concept: H. pylori antibiotic susceptibility tests using either phenotypic (culture-based) or molecular methods (polymerase chain reaction [PCR] or next-generation sequencing [NGS]) are becoming increasingly available in the United States. The incremental benefit of selecting an eradication regimen “tailored” to the antibiotic susceptibility profile compared with empiric selection of eradication therapy remains to be adequately defined and studied—for both treatment-naive and treatment-experienced patients. Based on expert consensus, we advise using antibiotic susceptibility testing whenever the choice of therapy remains unclear after taking into consideration any previous treatments for H. pylori infection, past antibiotic exposure more generally, and whether there is a documented history of penicillin allergy. | Good practice point: The validation and implementation of rapid, inexpensive kit-based PCR diagnostic and antimicrobial resistance tests promises to be a major advance in management. | |
| Good practice point: In resource-poor, high-prevalence regions in which diagnostic testing is not available, a history suggesting chronic ulcer disease—periodic upper gut pain and/or past or present melena—suggests a high likelihood of H. pylori ulcer disease and justifies empirical eradication therapy, especially in patients with no history or NSAID or aspirin use. | ||
| Patient Education | Not Addressed | Good practice point: Patients should always be advised that successful eradication depends on compliance with the treatment. Time should be taken to counsel the patient, explaining how to take the multidrug therapy and anticipating adverse side effects. The need to complete the treatment should be emphasized. Written or pictorial information may also aid compliance. |
| BQT (comprised of a bismuth salt, a nitroimidazole, tetracycline, and a proton pump inhibitor [PPI]) | Recommendation: In treatment-naive patients with H. pylori infection, optimized BQT is recommended as a first-line treatment option (strong recommendation; moderate quality evidence). | No Specific Recommendation |
| Recommendation: In treatment-naive patients with H. pylori infection, concomitant therapy is not suggested over BQT (conditional recommendation; low quality evidence). | ||
| Recommendation: In treatment-experienced patients with persistent H. pylori infection who have not previously received BQT, optimized BQT is suggested (conditional recommendation; very low quality of evidence). | ||
| Recommendation: In treatment-experienced patients with persistent H. pylori infection who have not previously received optimized BQT, optimized BQT is suggested over quinolone-based therapy (conditional recommendation; low quality of evidence). | ||
| Recommendation: In treatment-experienced patients with persistent H. pylori infection who have previously received PPI-clarithromycin triple therapy, optimized BQT is suggested (conditional recommendation; low quality of evidence). | ||
| Rifabutin Triple Therapy (Consists of a PPI, rifabutin, and amoxicillin) | Recommendation: In treatment-naive patients with H. pylori infection, rifabutin triple therapy is suggested as a first-line treatment option (conditional recommendation; low quality evidence) | No Specific Recommendation |
| Recommendation: In treatment-experienced patients with persistent H. pylori infection who have received BQT, rifabutin triple therapy is suggested (conditional recommendation; low quality of evidence). | ||
| PCAB (potassium-competitive acid blockers) and Amoxicillin Dual Therapy | Recommendation: In treatment-naive patients with H. pylori infection, dual therapy with a PCAB and amoxicillin is suggested as a first-line treatment option (conditional recommendation; moderate quality evidence). | No Specific Recommendation |
| Recommendation: In treatment-experienced patients with persistent H. pylori infection, there is insufficient evidence from North America to recommend high-dose PPI or PCAB dual therapy (no recommendation; evidence gap). | ||
| Regimens Containing Clarithromycin and Levofloxacin | Key concept: Clarithromycin- and levofloxacin-containing treatment regimens should be avoided in the absence of demonstrated macrolide and quinolone susceptibility, respectively. | No Specific Recommendation |
| Recommendation: In treatment-experienced patients with persistent H. pylori infection, levofloxacin triple therapy is suggested in patients with known levofloxacin-sensitive H. pylori strains and when optimized bismuth quadruple or rifabutin triple therapies have previously been used or are unavailable (conditional recommendation, low quality of evidence). | ||
| PCAP-Clarithromycin Triple Therapy | Key concept: In treatment-experienced patients with persistent H. pylori infection that is confirmed to be clarithromycin-sensitive, PPI- or PCAB-clarithromycin triple therapy is suggested. | Key statement: The major determinant of eradication success with PPI-AC is pretreatment clarithromycin resistance. |
| Recommendation: In treatment-naive patients with H. pylori infection and unknown clarithromycin susceptibility, PCAB-clarithromycin triple therapy is suggested over PPI-clarithromycin triple therapy (conditional recommendation; moderate quality evidence). | ||
| Test of Cure | Key concept: All patients who are treated for H. pylori infection should undergo a test of cure with an appropriately conducted urea breath test, fecal antigen test, or biopsy-based test at least 4 weeks after completion of therapy. | Not Addressed |
| Probiotic Therapy | Recommendation: There is insufficient evidence to suggest that the use of probiotic therapy improves the efficacy or tolerability of H. pylori eradication therapy (conditional recommendation; low quality of evidence). | Not Addressed |
This concludes our Guidelines Side-by-Side on H. pylori. Don’t forget to sign up for alerts to stay informed on the latest published guidelines and articles.
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