Management of Helicobacter pylori infections

Abstract

Background: Infection with Helicobacter pylori is associated with severe digestive diseases including chronic gastritis, peptic ulcer disease, and gastric cancer. Successful eradication of this common gastric pathogen in individual patients is known to prevent the occurrence of peptic ulcer disease and gastric cancer.

Discussion: With half of the world's population being infected with H, pylori and only few antibiotics result in an effective eradication, a successful antibiotic driven worldwide eradication program seems unlikely. In addition, H. pylori eradication is not always beneficial as it has been described that eradication can be associated with an increased frequency of other disorders such as pediatric asthma, inflammatory bowel diseases and Barrett's Esophagus. We have to accept that eradication of this infection is a two-edged sword that is both useful and harmful and we should therefore focus our H. pylori eradication policy toward selectively identify and destroy only the virulent strains.

Conclusion: In order to still be able to effectively treat H. pylori infections in the future we need an alternative diagnostic/treatment algorithm. This would involve a shift towards more precise and enhanced disease predicting diagnosis that tries to identify patients with chance of developing severe diseases such as gastric cancer, rather than the current regime that is geared towards find and destroy all H. pylori.

Keywords: Antimicrobial resistance; Eradication therapy; Gastric cancer; H. pylori.

Fig. 1

Stopping the Helicobacter pylori induced disease cascade. Depending on the host and bacterial characteristics the initial colonization will result in gastritis and this will either result in clinical symptoms (symptomatic patient) where screening for the presence of Helicobacter and its resistance needs to be performed in order to allow for rational treatment. If the infection does not result in clinical symptoms (asymptomatic patient) it may still be advisable to use a single non-invasive fecal antigen screen at age 40 or so (when usually symptoms have not yet developed) to test for the presence of Helicobacter. When this test is positive fecal DNA test detecting Helicobacter specific virulence factors to predict infection with a virulent strain, and/or a noninvasive serologic follow-up screen to establish the degree of atrophy is advisable. If either of these tests predict there is a high risk for the development of gastric cancer eradication is advisable. Elimination of strains that contain virulence markers associated with an increased risk for disease development (regardless of what pathogenicity - if any it is causing in its current host) will l reduce the spread of virulent strains and thereby force the population of circulating Helicobacter isolates into less pathogenic Helicobacters, irrespective of the contribution of host genetics and environmental factors