Helicobacter pylori best treatment approach: should a national consensus be the best consensus?

A significant number of national and international consensuses have been published in the literature during recent years concerning the treatment of Helicobacter pylori (H. pylori). These guidelines are aimed toward achieving an extremely high cure rate (≥90%), which seems to be unachievable in real-world settings, especially in areas with high clarithromycin resistance, such as southern Europe [1]. Times change quickly and, as with other infectious diseases, we are moving inevitably from a trial-and-error therapeutic approach to a susceptibility-based one. Empirical first-line treatments should be based on what works best in each geographical and/or national area and must take into account the prevalence of antimicrobial resistance in each region.

We have reviewed the basic conclusive suggestions from the existing guidelines and consensuses worldwide concerning the best anti-H. pylori treatment approach in relation to antibiotic resistance (Table 1) [2-13]. According to this global plethora of recommendations, it is worth remembering that the determinants of a successful H. pylori eradication could be divided into host-related (e.g., previous antibiotic exposure, patient’s adherence to a multi-drug regimen and/or genetic factors) and H. pylori-related factors, with antibiotic sensitivity appearing to be the most important and consistent predictor of success, both in clinical trials and in population-based studies of H. pylori eradication [14,15]. Thus, it is of major importance for a country’s clinical practitioners to know the local pattern of resistance. It seems apparent that an international consensus should play a major role in a specialist’s decision making, but it also appears quite reasonable and inevitable that a national consensus, based on nationwide surveys of first-line, second-line and rescue therapies, as well as the local prevalence of antibiotic resistance, should play the major role in each clinician’s judgment. In a recently published review, De Francesco et al provided a critical reappraisal of updated worldwide guidelines [16]. The authors fairly concluded that, although several of these guidelines highlighted that the results being achieved by an eradication therapy are population-specific and not directly transferable to another one, it emerged that some therapeutic regimens are recommended or discouraged with no mention of the need to consult existing national data. However, if solid susceptibility data are available for a specific population, then one could recommend or reject various therapeutic regimens for this population, because antimicrobial resistance seems to represent the key factor adversely affecting the outcome of eradication treatment. Nevertheless, each national study group and consensus panel should avoid taking isolated data from one study in a specific region of the country and arbitrarily generalizing them to the entire country’s population. On the other hand, this extrapolation seems to be generally accepted for one country if its susceptibility pattern has been thoroughly defined.

Table 1

Basic conclusive suggestions and data concerning the best approach to H. pylori treatment from the worldwide existing guidelines and consensuses in relation to antibiotic resistance

It seems that the best treatment approach to H. pylori is running at full speed toward treatments based on a national consensus that should exist for each country. Undoubtedly, guidelines of a neighboring country or a continental consensus could be used in a tutorial manner, particularly when local information is lacking.