The second Irish Helicobacter pylori Working Group consensus for the diagnosis and treatment of Helicobacter pylori infection in adult patients in Ireland

Abstract

Background: There has been an increase in resistance to many of the antimicrobials used to treat Helicobacter pylori ( H. pylori ) nationally and internationally. Primary clarithromycin resistance and dual clarithromycin and metronidazole resistance are high in Ireland. These trends call for an evaluation of best-practice management strategies.

Objective: The objective of this study was to revise the recommendations for the management of H. pylori infection in adult patients in the Irish healthcare setting.

Methods: The Irish H. pylori working group (IHPWG) was established in 2016 and reconvened in 2023 to evaluate the most up-to-date literature on H. pylori diagnosis, eradication rates and antimicrobial resistance. The 'GRADE' approach was then used to rate the quality of available evidence and grade the resulting recommendations.

Results: The Irish H. pylori working group agreed on 14 consensus statements. Key recommendations include (1) routine antimicrobial susceptibility testing to guide therapy is no longer recommended other than for clarithromycin susceptibility testing for first-line treatment (statements 6 and 9), (2) clarithromycin triple therapy should only be prescribed as first-line therapy in cases where clarithromycin susceptibility has been confirmed (statement 9), (3) bismuth quadruple therapy (proton pump inhibitor, bismuth, metronidazole, tetracycline) is the recommended first-line therapy if clarithromycin resistance is unknown or confirmed (statement 10), (4) bismuth quadruple therapy with a proton pump inhibitor, levofloxacin and amoxicillin is the recommended second-line treatment (statement 11) and (5) rifabutin amoxicillin triple therapy is the recommend rescue therapy (statement 12).

Conclusion: These recommendations are intended to provide the most relevant current best-practice guidelines for the management of H. pylori infection in adults in Ireland.

Fig. 1.

Treatment decision schematic. Bismuth quadruple therapy (PPI, bismuth, metronidazole and tetracycline/doxycycline if tetracycline is unavailable); Clarithromycin triple therapy (PPI, clarithromycin and amoxicillin); Levofloxacin quadruple therapy (PPI, bismuth, levofloxacin and amoxicillin); Rifabutin triple therapy (PPI, rifabutin and amoxicillin). *Other rescue therapy options include a PPI and bismuth in combination with two antimicrobials not previously prescribed. PPI, proton pump inhibitor.