Treatment options for Helicobacter pylori.👀

Helicobacter pylori (Hp) is a bacterium with a high infection rate in clinical practice. It can cause stomach ulcers and chronic gastritis and other stomach diseases. The long-term effects of these stomach problems can even lead to stomach cancer. Some studies have pointed out that the incidence of stomach disease caused by Hp is about 6 times that of stomach disease caused by other reasons. About 90% of patients with chronic gastritis and gastric ulcers carry Helicobacter pylori.

Indications for Helicobacter pylori.

The infection rate of Helicobacter pylori in the world is very high. Hp infection rates in some countries exceed 50%. Gastritis caused by Hp is an infectious disease. Treatment is generally necessary for Hp-positive patients. For Hp-positive patients with the following indications, they should undergo Hp eradication therapy. 

Eradication therapy is strongly recommended for Hp-positive patients with the following indications:

1. Peptic ulcer with or without activity and with or without a history of complications.
2. Gastric mucosa-associated lymphoid tissue.

Eradication therapy is recommended for Hp-positive patients with the following indications:

1. Has a family history of gastric cancer.
2. Chronic gastritis is accompanied by symptoms of gastric mucosal atrophy, erosion or indigestion.
3. Long-term use of proton pump inhibitors (PPIs).
4. The treatment plan requires long-term use of non-steroidal anti-inflammatory drugs.
5. Early gastric tumors have undergone endoscopic resection or subtotal gastrectomy.
6. Idiopathic thrombocytopenic purpura.
7. Unexplained iron deficiency anemia.
8. Other Hp-related diseases such as hyperplastic gastric polyps, lymphocytic gastritis.
9. Hp infection has been confirmed.

Drugs that can eradicate Helicobacter pylori.

The main treatment regimen for empirical eradication of Helicobacter pylori is PPI + 2 kinds of antibacterial drugs + bismuth. It is recommended to use for 10 or 14 days. Eradication rates with these regimens can reach 85 to 94%.

1. Proton pump inhibitors.

PPIs can inhibit the secretion of gastric acid and increase the pH of the stomach. It will increase the chemical stability of antibiotics, the concentration of antibiotics in the stomach and reduce the minimum inhibitory concentration to enhance the effect of antibiotics. In order to improve the eradication rate, it should generally be used the drugs with high curative effect, stable action and less influence by CYP2C19 gene polymorphisms, such as rabeprazole. They are generally recommended to be taken twice a day, half an hour before meals. 

1. Omeprazole: It is a first-generation PPI. Its recommended dose is 20mg daily. Its onset is slower.
2. Lansoprazole: It is a first-generation PPI. Its recommended dose is 30mg daily. It onset is faster than omeprazole.
3. Pantoprazole: It is a first-generation PPI. Its recommended dose is 40mg daily. It onset is similar to that of omeprazole.
4. Rabeprazole: It is a second-generation PPI. Its recommended dose is 10mg or 20mg daily. It onset is the fastest.
5. Esomeprazole: It is a second-generation PPI. Its recommended dose is 20mg daily. It onset is similar to that of lansoprazole.

2. Antibacterial drugs.

Acidic environments reduce their efficacy. It is generally recommended to take it after meals. The following are commonly used antibacterial drug combinations:

• Amoxicillin 2 times a day, 1000mg each time + Clarithromycin 2 times a day, 500mg each time.
• Amoxicillin 2 times a day, 1000mg each time + Levofloxacin 500mg once a day or 200mg twice a day.
• Amoxicillin 2 times a day, 1000mg each time + Furazolidone 2 times a day, 100 mg each time.
• Tetracycline 3 or 4 times a day, 500mg each time + Metronidazole 3 or 4 times a day, 400 mg each time.
• Tetracycline 3 or 4 times a day, 500mg each time + Furazolidone 2 times a day, 100 mg each time.
• Amoxicillin 2 times a day, 1000mg each time + Metronidazole 3 or 4 times a day, 400 mg each time.
• Amoxicillin 2 times a day, 1000mg each time + Tetracycline 3 or 4 times a day, 500mg each time.

Gastric acid had relatively little effect on the activity of tetracycline, metronidazole, and furazolidone. The other effects of gastric acid were amoxicillin > clarithromycin > levofloxacin.

3. Bismuth.

Bismuth pectin (undetermined standard dose) and bismuth citrate (220 mg) are recommended to be taken twice a day, half to one hour before meals. Stools will turn black after taking bismuth. Short-term use of bismuth for 1 to 2 weeks has a high safety. Helicobacter pylori is not resistant to bismuth because it is directly killed by bismuth. Bismuth can additionally increase the eradication rate of resistant strains of Hp by 30 to 40%. A quadruple regimen containing bismuth should be used whenever possible in the empirical treatment of Hp, unless the patient has a contraindication to bismuth or resides in a low resistance rate.

How to choose a treatment plan?

The choice of treatment regimen is to choose a combination of antibiotics. The choice of PPI and bismuth is generally not limited unless the patient has a contraindication or intolerance. The selection of antibiotics should be based on the patient's allergy history, medication history, and local Hp antibiotic resistance. Efficacy, cost, convenience, and adverse reactions should also be considered.

1. Initial empirical treatment.

The above combinations of antibacterial drugs are not divided into first-line or second-line. The combination with high efficacy should be used in the initial treatment. However, Combinations containing levofloxacin are not intended as initial treatment regimens. The main reason for the decrease in eradication rate is the increased drug resistance of Hp. If Hp is resistant to one of the two antibacterial drugs, the eradication rate drops to 50 to 60%. If Hp is resistant to both antibiotics, the eradication rate is only about 10%. Antibiotics were selected according to the resistance of local Hp. Drug susceptibility testing can be performed if necessary. Amoxicillin generally has a strong effect on Hp and is not easy to develop drug resistance. Patients without allergies have fewer adverse reactions. It can be considered as the first choice. Furazolidone has more serious adverse reactions. It is only used for Hp infections that are difficult to eradicate.

Primary resistance rate of Hp:

	Resistance rate
Amoxicillin	0-5%
Clarithromycin	20-50%
Furazolidone	0-1%
Levofloxacin	20-50%
Metronidazole	40-70%
Tetracycline	0-5%

Eradication rates and incidence of adverse effects of treatment regimens:

	Eradication rate	The incidence of adverse reactions
Amoxicillin + Clarithromycin	85-94%	Low
Amoxicillin + Levofloxacin	85-89%	Medium
Amoxicillin + Tetracycline	85-89%	Medium
Tetracycline + Metronidazole	85-94%	Medium to high
Tetracycline + Furazolidone	85-94%	Medium to high
Amoxicillin + Metronidazole	85-94%	Medium to high
Amoxicillin + Furazolidone	85-94%	Medium to high

2. After failure of initial treatment.

Choose one of the remaining treatment options for treatment. The selection should refer to past treatment regimens. It is generally not reused. 

Metronidazole at conventional doses is fully functional when Hp is not resistant, but it is completely ineffective when resistant. Its dose can increase to 1600mg daily in 4 divided doses to overcome drug resistance. Therefore, if repeated use of metronidazole is required, its dose needs to be increased to 1600 mg per day. When this dose has been used for the initial treatment, it should not be used again. 

In addition, increasing the dose of metronidazole (1600mg/day) or furazolidone (300mg/day) can improve the efficacy, but the adverse reactions will also increase.

3. Treatment of patients with penicillin allergy.

Tetracycline can be used instead of amoxicillin. It is recommended to use tetracycline in combination with furazolidone or metronidazole. Tetracycline combined with levofloxacin is also effective.

When tetracycline cannot be used, clarithromycin can be used instead. Such as clarithromycin combined with furazolidone, metronidazole or levofloxacin.

Prevention of Hp.

The main route of Hp infection is the digestive tract. Saliva can be its carrier. Therefore, pay attention to the hygiene of tableware and disinfect regularly.

Studies have shown that Hp can survive in fresh water for at least 3 years. It also survives 4 to 10 days in tap water. Water should be cooked thoroughly before drinking.

The development of an Hp vaccine may be the best way to prevent infection in the future.