Source: Digestive and Liver Disease Channel of the Medical CommunityHelicobacter pylori（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], which can be described as the “Internet celebrity” bacteria in recent years. 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 the prevention, control and management of Helicobacter pylori infection in Chinese households(2021)“[3] pointed out that eradication therapy should be considered for all adults with Hp infection in the family.
- “The Sixth National Consensus Report on the Management of Helicobacter pylori Infection(non-eradication treatment part)“ [4] (hereinafter referred to as the “National Six Consensus”)Recommendations:
1) Eradication The benefits and risks of H. pylori vary among individuals, and individuals with infection should be evaluated and managed 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 spread of H. pylori among family members. Spread. Summary of these latest consensuses, 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 plan 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 current clinical issues, We will summarize these issues below. and induction.
- Do children need H. pylori eradication?
- Is it necessary for the elderly to undergo Hp eradication therapy?
- How to treat penicillin allergy?
- Do pregnant and lactating patients need eradication?
Do children need Hp infection eradication?
Generally, people over 14 years old go to internal medicine, and under 14 years old go to pediatrics, but the diagnosis and treatment of Hp in children is very difficult clinically. , Pediatricians believe that this is a professional gastroenterology problem and should go to the gastroenterology outpatient clinic, but gastroenterologists believe that it is better for children to decide on the problem of medication for children. Faced with such a dilemma, what should we do? First of all, the currently accepted recommendation is not to recommend routine testing for H. pylori in children under the age of 14 for three reasons [6]: 1. Compared with adults, children with H. pylori infection have a lower risk of serious diseases including peptic ulcer, atrophic gastritis and gastric cancer;2. There are many unfavorable factors for eradication therapy, including There are few options for 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 the detection and eradication of H. pylori. For example, “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. Radical treatment may 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, older children strongly demand 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 once. At the same time, it should be noted that “Expert Consensus on the Prevention, Control and Management of Helicobacter pylori Infection in Chinese Residents’ Households(2021)“[3] also pointed out that most of the H. Symptoms, it is also recommended that for the health of adolescents and children, the adult H. pylori infection in the family should actively eradicate H. pylori in the absence of contraindications. 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. Treatment Hp in the elderly is also beneficial to improve gastrointestinal symptoms such as gastritis and peptic ulcer, so early treatment of the elderly is very 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 may easily lead to gastrointestinal damage and increased risk of gastrointestinal bleeding. High [9], the eradication of H. pylori before the planned medication can significantly benefit[4]. H. pylori eradication therapy for elderly patients should pay special attention to the following points: ①Drug interaction risk[10 ], partial proton pump inhibitor (PPI)After being metabolized by CYP2C19, drug interactions will occur due to co-competition with clopidogrel for the same binding site of CYP2C19 in vivo, affecting the efficacy. ②Elderly patients have more opportunities to be exposed to various antibiotics, which may lead to stronger H. ③The older people may carry bacteria longer, which may lead to gastric mucosal atrophy, intestinal metaplasia, dysplasia and even early gastric cancer.[9], therefore, it is recommended that elderly patients with Hp infection should 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 for treatment. Physicians must obtain a complete and accurate allergy history (including a description of the allergy symptoms and the time of the allergy onset) and consider penicillin skin testing for early evaluation to determine whether the patient is Resistant to penicillin or amoxicillin[8]. The new version of the “National Sixth Consensus” recommends that for patients with penicillin allergy, the bismuth quadruple regimen containing tetracycline and metronidazole is the first choice as the empirical eradication treatment regimen[12 ]. The new antibiotic combination is shown in Table 1 below(14-day course of treatment):Table 1 New Antibiotic Combinations Recommended by “China VI Consensus”
The combination of clarithromycin, levofloxacin, and metronidazole, which is often used in the past, is generally ineffective. , may have better eradication efficacy. Alternatively, use semi-synthetic tetracycline instead of tetracycline (eg, minocycline 100 mg twice a day). Do pregnant and lactating patients need Hp eradication?< span>[11]?
Limited options for safe medication use during pregnancy and lactation make It is more difficult to treat Hp. 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]. Chinese Journal of Digestive Medicine, 2021, 41(4): 13.
[4] Helicobacter pylori (Hp) Group of Digestive Disease Branch of Chinese Medical Association. National consensus report on the management of Helicobacter pylori infection (part of non-eradication therapy)”[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 Pediatrics 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.(201 9).Treatment of Helicobacter pylori in Special Patient Populations.[J]Pharmacotherapy:39.10.1002/phar.2318.
[9]Wang Jiangbin. Elderly Helicobacter pylori infected patients eradication therapyBenefit/risk evaluation and antibiotic application related issues in Chinese medicine[J].Chinese Journal of Medicine,2020,100(30):2343-2345.
[10] “Proton Pump” Guidelines for Clinical Application of Inhibitors (2020 Edition) http://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 Digestive Disease Branch of Chinese Medical Association. “The Sixth National Guidelines for the Treatment of Helicobacter pylori Infection”. Data on file.
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