Consensus on the clinical management, screening-to-treat, and surveillance of Helicobacter pylori infection to improve gastric cancer control on a nationwide scale

Abstract

Background: Previous international consensus statements provided general policies for the management of Helicobacter pylori infection. However, there are geographic differences in the prevalence and antimicrobial resistance of H. pylori, and in the availability of medications and endoscopy. Thus, nationwide or regional consensus statements are needed to improve control of H. pylori infection and gastric cancer.

Materials and methods: This consensus statement for management of H. pylori in Taiwan has three major sections: (1) optimal diagnosis and indications; (2) current treatment strategies; and (3) screening-to-treat and surveillance for control of gastric cancer. The literature review emphasized recent data for development of draft statements and determination of levels of evidence. Twenty-five Taiwan experts conducted a consensus conference, by a modified Delphi process, to modify the draft statements. Consensus, defined as an agreement of least 80% of the experts, and recommendation grade were determined by anonymous voting.

Results: There were 24 consensus statements. Section 1 has seven statements on recommendations for the diagnosis and indications for treatment of H. pylori infection. Section 2 has 10 statements that provide an updated treatment algorithm for first-line, second-line, and third-line regimens. Section 3 has seven statements regarding H. pylori eradication for reducing the risk of gastric cancer, with a cost-benefit analysis. After H. pylori eradication, the consensus highlights the use of endoscopic surveillance and/or chemoprevention to further reduce the burden of gastric cancer.

Conclusions: This consensus statement has updated recommendations for improving the clinical management of H. pylori infection in areas such as Taiwan, which have high prevalence of H. pylori infection and gastric cancer.

Keywords: Helicobacter pylori; consensus; endoscopy; eradication; gastric cancer; gastric precancerous lesion; level of evidence; peptic ulcer; proton-pump inhibitor.

Figure 1

The algorithm for the recommended treatment of H. pylori infection (Agreement: 100%). In areas with low clarithromycin resistance (≤15%), a 14‐d clarithromycin‐based therapy (hybrid, sequential, concomitant, or triple therapy) is the treatment of choice; a levofloxacin‐based therapy and quadruple therapy are effective second‐line (rescue) therapies. A 10‐ to 14‐d bismuth quadruple therapy is a suitable alternative first‐line therapy; a levofloxacin‐based therapy is suitable as a second‐line (rescue) therapy. The dashed lines in the figure indicate the lack of high level of evidence. In areas with high clarithromycin resistance (>15%), a 10‐ to 14‐d bismuth quadruple therapy is effective; a levofloxacin‐based is suitable as a second‐line (rescue) therapy; a 14‐d hybrid or concomitant therapy is an alternative first‐line therapy; a bismuth quadruple therapy is suitable as a second‐line (rescue) therapy. Drug choice guided by susceptibility testing should be used for patients who fail two eradication therapies