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Special groups include: children, the elderly, pregnant women, etc.
Helicobacter pylori (Hp) is the most important but controllable risk factor for gastric cancer. The infection rate of H. pylori in my country is as high as 55.8%[1]. “bacteria. Recently, my country has published a number of guidelines/consensus on the prevention and treatment of H. pylori, all of which put forward positive suggestions for the eradication of H. pylori.
Screening and eradication of Helicobacter pylori to prevent gastric cancer: a global consensus in Taipei[2] Recommendation: Evidence supports the recommendation that all people infected with H. pylori should receive eradication therapy. High-risk groups should be tested and, if they test positive, eradication therapy. Mass screening and eradication of H. pylori should be considered in high-risk populations for gastric cancer.
“Expert Consensus on Prevention, Control and Management of Helicobacter pylori Infection in Chinese Residents’ Families (2021)”[3] pointed out that eradication should be considered for all adults with H. pylori infection in the family treat.
“The Sixth National Consensus Report on the Treatment of Helicobacter pylori Infection (Non-eradication Treatment Part)”[4] (hereinafter referred to as the “National Six Consensus”) recommends:
1) The benefits and risks of H. pylori eradication vary among individuals, and individuals with infection should be evaluated and treated individually.
2) H. pylori gastritis is a contagious infectious disease. For adults in the family who live with the infected person and have no competing factors, it is recommended to detect and eradicate H. pylori to block the Transmission among family members.
Summary of these latest consensus, it is not difficult to see that for the general population of H. pylori infection, the recommendations for detection and eradication treatment are very clear. And it is emphasized that one-time eradication is successful, and it is necessary to choose a program with an eradication rate of more than 90% [5].
However, whether and how to eradicate H. pylori in some special populations is still the focus of the current clinical issues, We will summarize these issues below. induction.
Do children need Hp infection eradication?
Is it necessary for the elderly to undergo Hp eradication therapy?
How is a penicillin allergy treated?
Do pregnant and lactating patients require eradication?
Do children need H. pylori eradication?
In general, people over 14 years old go to internal medicine, and under 14 years old go to pediatrics. However, the diagnosis and treatment of children’s Hp is very difficult clinically. Pediatricians think it is a professional gastroenterology problem. You should go to the outpatient department of gastroenterology, but the gastroenterologist believes that it is better for the pediatrician to decide the problem of medication for children. Faced with such a dilemma, what should we do?
First, the generally accepted recommendation is that routine testing for Hp in children under 14 is not recommended for three reasons[6]:
1. Compared with adults, children with H. pylori infection have a lower risk of developing serious diseases including peptic ulcer, atrophic gastritis and gastric cancer;
2. There are many unfavorable factors for eradication therapy, including limited choice of antibiotics (only amoxicillin, clarithromycin and metronidazole are recommended). In addition, children have low tolerance to adverse drug reactions, which affects treatment compliance and makes it difficult to carry out a full course of treatment.
3. Children with H. pylori infection have a certain spontaneous clearance rate, and the re-infection rate after eradication may also be higher than that of adults.
However, some children will benefit greatly from detection and eradication of H. pylori. For example, the “Expert Consensus on the Diagnosis and Treatment of Helicobacter pylori Infection in Children” [7] recommends that children with peptic ulcer and gastric MALT lymphoma must be cured of Hp infection. Radical treatment can be considered in the following cases: chronic gastritis, family history of gastric cancer, unexplained refractory iron-deficiency anemia, planned long-term use of non-steroidal anti-inflammatory drugs (including low-dose aspirin), guardians, and elderly children who strongly require treatment.
Therefore, in addition to the above-mentioned children, it is recommended that children with Hp infection should undergo regular eradication treatment after they become adults, and the eradication is successful at one time.
At the same time, it should be noted that the “Expert Consensus on the Prevention, Control and Management of Helicobacter pylori Infection in Chinese Residents’ Families (2021)” [3] also pointed out that most H. pylori infections occur in Children and adolescents can also be infected in adulthood, and Hp is a pathogenic bacteria that can be transmitted among family members. It also suggests that even if there are no symptoms, it is recommended that for the health of adolescents and children, adult H. In the absence of contraindications, actively eradicate H. pylori.
Do the elderly still need to eradicate H. pylori infection?
Aging is a risk factor for H. pylori infection and related complications such as peptic ulcer, functional dyspepsia, and gastric malignancy. Treating H. pylori in the elderly is also beneficial for improving gastritis and digestion. ulcers and other gastrointestinal symptoms, so early treatment in the elderly population is important[8].
On the other hand, the elderly are often accompanied by chronic underlying diseases such as cardiovascular and cerebrovascular diseases, and need to be treated with antiplatelet and anticoagulant drugs, which can easily lead to gastrointestinal damage and increase the risk of gastrointestinal bleeding. [9], the eradication of H. pylori before the intended medication can significantly benefit [4].
H. pylori eradication therapy for elderly patients requires special attention to the following points:
Drug interaction risk[10], some proton pump inhibitors (PPIs) are metabolized by CYP2C19, and drug interactions may occur due to co-competition with clopidogrel for the same binding site of CYP2C19 in vivo effect, affect the curative effect.
Elderly patients have more opportunities to be exposed to various antibiotics, which may lead to stronger H. pylori drug resistance and more difficult eradication in elderly patients [9].
Older people may carry bacteria longer, leading to gastric mucosal atrophy, intestinal metaplasia, and abnormal growth in the stomach.Therefore, elderly patients with H. pylori infection are recommended to actively undergo gastroscopy.
The recommendations for the treatment of H. pylori in the elderly are the same as in the general population. Appropriate monitoring and follow-up are important to assess potential treatment-related adverse reactions that may affect adherence to and efficacy of drug regimens.
How is a penicillin allergy treated?
Treatment of penicillin-allergic H. pylori patients is difficult. Because amoxicillin, which belongs to the penicillin class, is one of the most effective antibiotics against H. pylori and has low rates of primary resistance in most regions, it is an integral part of many first- and second-line treatment regimens. But about 10 percent of people are allergic to penicillin, leaving doctors with fewer options when it comes to treatment. Physicians must obtain a complete and accurate allergy history (including a description of allergy symptoms and the timing of allergy onset) and consider penicillin skin testing for early evaluation to determine patient tolerance to penicillin or amoxicillin [8].
The new version of the “National Sixth Consensus” recommends that for patients allergic to penicillin, the bismuth quadruple regimen containing tetracycline combined with metronidazole is the first choice as the empirical eradication therapy [12]. The new antibiotic combination is as follows in Table 1(14-day course of treatment):
Table 1 New Antibiotic Combinations Recommended by the Sixth National Consensus
Combination of clarithromycin, levofloxacin and metronidazole commonly used in clinical practice is generally ineffective, but when full dose metronidazole (1.6g/day) is used, it may Get better eradication efficacy. Alternatively, use a semisynthetic tetracycline instead of tetracycline (eg, minocycline 100 mg twice a day).
Do pregnant and lactating patients need Hp eradication[11]?
Limited options for safe medication during pregnancy and breastfeeding make treating H. pylori difficult in these situations. Both bismuth and tetracycline have teratogenic effects in the drugs used to eradicate H. pylori. Based on the association between H. pylori and the risk of disease progression, as well as the comprehensive consideration of the benefits and risks of treatment drugs, In principle, H. pylori eradication therapy during pregnancy is not recommended. In rare cases, patients with a positive Hp test are asymptomatic and treatment should be delayed until after delivery or cessation of breastfeeding.
References:
[1]Hooi JKY,Lai WY,Ng WK,et al.Global prevalence of Helicobacter pylori infection:systematic review and meta-analysis[J].Gastroenterology.2017;153(2) :420-429.
[2]Liou J-M,et al.Screening and eradication of Helicobacter pylori for gastric cancer prevention:the Taipei global consensus[J].Gut 2020;0:1–20.doi:10.1136 /gutjnl-2020-322368.
[3] National Clinical Research Center for Digestive Diseases (Shanghai), et al. Expert consensus on the prevention, control and management of Helicobacter pylori infection in Chinese households (2021) [J]. Digestive Journal, 2021, 41(4):13.
[4] Helicobacter pylori (Hp) group of Chinese Medical Association Digestive Disease Branch. “The Sixth National Consensus Report on the Management of Helicobacter pylori Infection (Part of Non-eradication Treatment)”[J ]. Chinese Journal of Digestion. 2022 42(5):289-303.
[5]Granham DY.Helicobacter pylori therapy: a paradigm shift[J].Expert Rev Anti Infect Ther.2016;14:577-585.
[6] Liu Wenzhong, Xie Yong, Lu Hong, et al. The fifth national consensus report on the management of Helicobacter pylori infection [J]. Chinese Journal of Practical Internal Medicine. 2017, 37(6): 509-524.
[7] Gastroenterology Group of Pediatric Branch of Chinese Medical Association, et al. Expert consensus on diagnosis and treatment of Helicobacter pylori infection in children [J]. Chinese Journal of Pediatrics, 2015, 53(7): 496- 498.
[8]Nguyen,Cynthia&Davis,Kyle&Nisly,Sarah&Li,Julius.(2019).Treatment of Helicobacter pylori in Special Patient Populations.[J]Pharmacotherapy:39.10.1002/phar.2318.< /p>
[9] Wang Jiangbin. Benefit/risk evaluation of eradication therapy in elderly patients with Helicobacter pylori infection and issues related to antibiotic use [J]. Chinese Journal of Medicine, 2020, 100(30): 2343 -2345.
[10] “Guidelines for the Clinical Application of Proton Pump Inhibitors (2020 Edition)” http:https://www.nhc.gov.cn/cms-search/xxgk/getManuscriptXxgk.htm ?id=9aac2b191c844082aac2df73b820948f
[11] Mao Yimin. Pay attention to the management of common digestive system diseases during pregnancy [J]. Gastroenterology, 2014,19(12).705-711.
[12] Helicobacter pylori (Hp) group of Chinese Medical Association Gastroenterology Branch. “The Sixth National Guidelines for the Treatment of Helicobacter pylori Infection”. Data on file.
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