First regional consensus on the management of Helicobacter pylori infection in the Middle East

Abstract

Helicobacter pylori (H. pylori), a widespread gram-negative bacterium that colonizes the stomach, causes chronic gastritis, which may progress to peptic ulcer, mucosa-associated lymphoid tissue lymphoma, and gastric cancer. H. pylori infection affects over 50% of people in developing countries and 10%-20% in developed countries. The Kyoto consensus classifies H. pylori gastritis as an infectious disease in the International Classification of Disease 11^th Revision. The Maastricht/Florence consensus recommends treatment for all infected individuals, introducing a shift in the management strategies. The prevalence of H. pylori infection is high in the Middle East, with infection rates of 40%-70% and 85%-90% being reported among children and adults, respectively. The increasing resistance to antibiotics, including macrolides and fluoroquinolones, is a major challenge in the management of H. pylori. Clarithromycin resistance, which is associated with reduced effectiveness of standard triple therapy regimens, leading to higher rates of treatment failure, impacts the eradication rates. This emphasizes the need for routine antibiotic susceptibility testing at the national level, the use of alternative therapies, including new molecular methods, and antibiotic stewardship. An online panel of experts from the Middle East, along with an international expert, developed this consensus to provide comprehensive guidelines on the diagnosis, treatment, prevention, and role of gut microbiota in H. pylori infection, with the goal of improving clinical decision-making and reducing the impact of antibiotic resistance in the region. These guidelines are intended to support healthcare professionals involved in the diagnosis and management of H. pylori, including primary care physicians, gastroenterologists, and other specialists. They may also inform future clinical research aimed at optimizing treatment strategies and addressing regional challenges.

Keywords: Antibiotic resistance; Consensus guidelines; Gastric cancer; Gut microbiota; Helicobacter pylori.

Figure 1

Regional prevalence of Helicobacter pylori (studies are highly variable in terms of diagnostic method use, setting and study population, and year of study).

Figure 2

Algorithm for empirical Helicobacter pylori eradication if individual antibiotic susceptibility testing is not available. ¹High-dose proton pump inhibitor (PPI) or potassium-competitive acid blocker (vonoprazan where available) plus amoxicillin may be another option. ²Bismuth Quadruple Single Capsule[1]. Bismuth Quadruple Single Capsule: PPI; bismuth, tetracycline; and metronidazole. Clarithromycin triple: PPI; clarithromycin; and amoxicillin. It is only used if proven effective locally or if clarithromycin sensitivity is known. Non-bismuth quadruple (concomitant): PPI; clarithromycin; amoxicillin; and metronidazole. Levofloxacin quadruple: PPI; levofloxacin; amoxicillin; and bismuth. Levofloxacin triple: The same but without bismuth. In cases of high fluoroquinolone resistance (> 15%), the combination of bismuth with other antibiotics, high-dose PPI-amoxicillin dual, or rifabutin, may be an option. BQT: Bismuth quadruple therapy; HDDT: High dose dual therapy; P-CAB: Potassium-competitive acid blockers; PPI: Proton pump inhibitor.