Clinical Evidence Concise: A Publication of BMJ Publishing Group
Helicobacter pylori Infection
Am Fam Physician. 2003 Jun 1;67(11):2359-2360.
What are the effects of treatments?
Helicobacter pylori eradication for healing and preventing recurrence of duodenal ulcer. Systematic reviews and one subsequent randomized controlled trial (RCT) have found that H. pylori eradication versus acid suppression or antisecretory treatment increases the proportion of ulcers healed at six weeks and reduces one-year recurrence. One systematic review has found that H. pylori eradication versus ulcer healing alone or versus ulcer treatment plus subsequent acid suppression maintenance treatment significantly reduced the risk of rebleeding.
H. pylori eradication for healing and preventing recurrence of gastric ulcer. One systematic review has found that H. pylori eradication treatment versus antisecretory treatment significantly reduces recurrent ulcers at one year. Observational evidence identified by the review found that eradication treatment heals 83 percent of gastric ulcers within six weeks of starting treatment. We found no RCTs of H. pylori eradication treatment on preventing complications of gastric ulcers.
LIKELY TO BE BENEFICIAL
H. pylori eradication for nonulcer dyspepsia. One systematic review in people with nonulcer dyspepsia has found that H. pylori eradication versus placebo significantly reduces dyspeptic symptoms at three to 12 months.
H. pylori eradication rather than empirical acid suppression for uninvestigated dyspepsia. One RCT found that H. pylori eradication versus placebo significantly increased relief from dyspeptic symptoms after one year.
H. pylori eradication rather than endoscopy in people with uninvestigated dyspepsia not at risk of malignancy. One systematic review and one subsequent RCT have found no significant difference between H. pylori testing plus eradication versus management based on initial endoscopy in dyspepsia after one year.
Three-day quadruple regimen (versus one-week triple regimen). One RCT comparing a three-day quadruple regimen with a one-week triple regimen found no significant difference in H. pylori eradication at six weeks, but found that people taking the three-day quadruple regimen experienced significantly fewer days of adverse effects.
Triple regimen (versus dual regimen). We found no systematic review or RCTs of the effects of dual regimen versus triple regimen on dyspeptic symptom scores, proportion of subjects with symptoms, quality of life, or mortality. One systematic review has found that dual versus triple regimens eradicate H. pylori from fewer people.
Two-week triple regimen (versus one-week triple regimen). One systematic review found that 14 versus seven days of treatment with proton pump inhibitor-based triple regimens significantly increased H. pylori cure rates.
H. pylori eradication for gastric B-cell lymphoma. We found no RCTs of H. pylori eradication treatment in people with gastric B-cell lymphoma. Observational studies found limited evidence that 60 to 93 percent of people with localized, low-grade B-cell lymphoma respond to H. pylori eradication treatment, avoiding the need for radical surgery, radio-therapy, or chemotherapy.
H. pylori eradication for prevention of gastric cancer (adenocarcinoma). We found no RCTs of H. pylori eradication in people at risk of gastric cancer. One RCT in people with gastric atrophy or intestinal metaplasia found that H. pylori eradication versus no eradication increased the regression of high-risk lesions. We found consistent evidence from observational studies of an association between H. pylori infection and increased risk of distal gastric adenocarcinoma of the stomach.
One triple regimen versus another. We found no systematic review or RCTs of the effects of different triple regimens on dyspeptic symptom scores, proportion of subjects with symptoms, quality of life, or mortality. One systematic review has found that clarithromycin 500 mg twice daily versus clarithromycin 250 mg twice daily plus a proton pump inhibitor plus amoxicillin significantly increases H. pylori eradication, but found no significant difference between clarithromycin 500 mg twice daily versus clarithromycin 250 mg twice daily plus a proton pump inhibitor plus metronidazole in H. pylori eradication rates. Another systematic review has found that a triple regimen containing ranitidine bismuth plus clarithromycin plus metronidazole versus a triple regimen containing ranitidine bismuth plus clarithromycin plus amoxicillin significantly increases eradication at five to seven days.
UNLIKELY TO BE BENEFICIAL
H. pylori eradication in people with gastroesophageal reflux disease. One RCT in people with gastroesophageal reflux disease found no significant difference with H. pylori eradication treatment versus placebo in symptomatic relapse.
H. pylori is a gram-negative flagellated spiral bacterium found in the stomach. Infection with H. pylori is predominantly acquired in childhood. The organism is associated with lifelong chronic gastritis and may cause other gastro-duodenal disorders.
H. pylori prevalence rates vary with birth cohort and social class in the developed world. Prevalence rates in many developed countries tend to be much higher (50 to 80 percent) in those born before 1950 in comparison to rates (less than 20 percent) in those born more recently. In many developing countries, the infection has a high prevalence (80 to 95 percent) irrespective of the period of birth.1 Adult prevalence is believed to represent the persistence of a historically higher rate of infection acquired in childhood, rather than increasing acquisition of infection during life.
Overcrowded conditions associated with childhood poverty lead to increased transmission and higher prevalence rates. Adult reinfection rates are low—less than 1 percent a year.1
H. pylori infection is believed to be causally related to the development of duodenal and gastric ulceration, gastric B-cell lymphoma, and distal gastric cancer. About 15 percent of people infected with H. pylori will develop a peptic ulcer, and 1 percent of people will develop gastric cancer during their lifetime.2 H. pylori infection is not associated with a specific type of dyspeptic symptom.
search date: April 2002
Adapted with permission from Delaney BC, Moayyedi P, Forman D. Helicobacter pylori infection. Clin Evid Concise 2003;9:92–4.
1. Axon AT. Helicobacter pylori infection. J Antimicrob Chemother. 1993;32(suppl A):61–8.
2. Graham DY. Can therapy ever be denied for Helicobacter pylori infection? Gastroenterology. 1997;113:S113–7.
This is one in a series of chapters excerpted from Clinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom. Clinical Evidence Concise is published in print twice a year and is updated monthly online. Each topic is revised every eight months, and users should view the most up-to-date version atwww.clinicalevidence.com. If you are interested in contributing to Clinical Evidence, please contact Claire Folkes (firstname.lastname@example.org). This series is part of the AFP's CME. See “Clinical Quiz” on page 2257.
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