Letter to the Editor Open Access
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Oct 16, 2022; 10(29): 10817-10819
Published online Oct 16, 2022. doi: 10.12998/wjcc.v10.i29.10817
Helicobacter pylori treatment guideline: An Indian perspective”: Letter to the editor
Raktim Swarnakar, Shiv Lal Yadav, Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, New Delhi-110029, India
ORCID number: Raktim Swarnakar (0000-0002-7221-2825).
Author contributions: Swarnakar R designed and analyzed the letter; Swarnakar R and Yadav SL performed the research and wrote the letter.
Conflict-of-interest statement: All authors declare that they have no conflict of interest to disclose.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Raktim Swarnakar, MBBS, MD, Doctor, Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, New Delhi-110029, India. raktimswarnakar@hotmail.com
Received: July 9, 2022
Peer-review started: July 9, 2022
First decision: August 1, 2022
Revised: August 2, 2022
Accepted: September 1, 2022
Article in press: September 1, 2022
Published online: October 16, 2022


Treatment guidelines in many countries for Helicobacter pylori (H. pylori) may differ. Owing to the various characteristics of bacteria, clinical manifestations, resistance to antibiotics and recurrence rate, treatment regimens may change. In this letter, we would like to give an Indian perspective on H. pylori treatment guidelines.

Key Words: Helicobacter pylori, Guidelines, Antibiotics, India, Perspective, Infection

Core Tip: A high prevalence of Helicobacter pylori (H. pylori) has been observed in many areas of India. There are recent guidelines and consensus on the management of H. pylori in India. We would like to correlate our guidelines with other existing guidelines through this letter-to-the-editor article.


We read with interest the review article by Cho et al[1] where they have shown Helicobacter pylori (H. pylori) treatment guidelines in different countries. We would like to add views from India and the guidelines followed in India[2]. We hope this letter would be an insight into a better understanding of treatment regimens since the prevalence of H. pylori is very high (nearly 80%) in the indigent populations of many developing countries[3].

Currently, the first line of management (low clarithromycin resistance) is the combination of proton pump inhibitors, amoxicillin and clarithromycin for 2 wk and in clarithromycin resistance areas, bismuth-based quadruple therapy is the first line of management. Imidazole-based therapy is not recommended for eradication. It is better to avoid less than 14 d of treatment. Fluoroquinolone-based concomitant therapy may be tried only after failure of second-line management[4]. The American College of Gastroenterology also has similar recommendations[5]. Considering salvage therapies which include standard triple therapy that has not been previously used, bismuth-based quadruple therapy, levofloxacin-based therapy or rifabutin-based triple therapy[2]. In India, antibiotic susceptibility testing–based therapy is considered an option as third-line rescue therapy though not compulsory. Furthermore, periodic monitoring of antimicrobial susceptibility patterns can provide general guidelines with the aim to eradicate H. pylori[6].

Unusually low prevalence of gastric cancer (GC) has been seen despite having a high prevalence of H. pylori in India owing to diet and genetic variations as seen in Indian patients[7]. This is the probable reason why routine H. pylori eradication to prevent GC in the Indian population is not recommended[2].

Resistance is the common cause of treatment failure and it depends upon the local variations of resistance. In India, as well in some other places, a high level of antimicrobial resistance and a high recurrence rate has been observed. That is why concomitant therapy is advisable more than sequential therapy in places with high antimicrobial resistance in India. Moreover, in India, multiple strains of H. pylori have been seen to infect a single host at the same time and reinfection chances are also high which differs from western countries.

It is important to collaborate research at the genetic level to find out the epidemiological cause of antimicrobial resistance, which mutation is causing such resistance and treatment failure. In developing and developed countries differences in epidemiological factors may contribute to the prevalence of resistant cases.

This review has nicely addressed the fact that there are differences in guidelines but it also needs to include many perspectives on guidelines from the developing and developed worlds, so that with more comprehensive precision medicine, we may develop in the future.


Provenance and peer review: Unsolicited article; Externally peer reviewed.

Peer-review model: Single blind

Specialty type: Infectious diseases

Country/Territory of origin: India

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): 0

Grade C (Good): C, C

Grade D (Fair): D

Grade E (Poor): 0

P-Reviewer: Bieńkowski C, Poland; Fujimori S, Japan; Sitkin S, Russia S-Editor: Liu JH L-Editor: Filipodia P-Editor: Liu JH

1.  Cho JH, Jin SY. Current guidelines for Helicobacter pylori treatment in East Asia 2022: Differences among China, Japan, and South Korea. World J Clin Cases. 2022;10:6349-6359.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 7]  [Cited by in F6Publishing: 7]  [Article Influence: 7.0]  [Reference Citation Analysis (7)]
2.  Singh SP, Ahuja V, Ghoshal UC, Makharia G, Dutta U, Zargar SA, Venkataraman J, Dutta AK, Mukhopadhyay AK, Singh A, Thapa BR, Vaiphei K, Sathiyasekaran M, Sahu MK, Rout N, Abraham P, Dalai PC, Rathi P, Sinha SK, Bhatia S, Patra S, Ghoshal U, Poddar U, Mouli VP, Kate V. Management of Helicobacter pylori infection: The Bhubaneswar Consensus Report of the Indian Society of Gastroenterology. Indian J Gastroenterol. 2021;40:420-444.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 5]  [Cited by in F6Publishing: 5]  [Article Influence: 2.5]  [Reference Citation Analysis (7)]
3.  Thirumurthi S, Graham DY. Helicobacter pylori infection in India from a western perspective. Indian J Med Res. 2012;136:549-562.  [PubMed]  [DOI]  [Cited in This Article: ]
4.  Marin AC, Nyssen OP, McNicholl AG, Gisbert JP. Efficacy and Safety of Quinolone-Containing Rescue Therapies After the Failure of Non-Bismuth Quadruple Treatments for Helicobacter pylori Eradication: Systematic Review and Meta-Analysis. Drugs. 2017;77:765-776.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 19]  [Cited by in F6Publishing: 15]  [Article Influence: 2.5]  [Reference Citation Analysis (0)]
5.  Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017;112:212-239.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 744]  [Cited by in F6Publishing: 743]  [Article Influence: 123.8]  [Reference Citation Analysis (1)]
6.  Datta S, Chattopadhyay S, Patra R, De R, Ramamurthy T, Hembram J, Chowdhury A, Bhattacharya SK, Berg DE, Nair GB, Mukhopadhyay AK. Most Helicobacter pylori strains of Kolkata in India are resistant to metronidazole but susceptible to other drugs commonly used for eradication and ulcer therapy. Aliment Pharmacol Ther. 2005;22:51-57.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 31]  [Cited by in F6Publishing: 31]  [Article Influence: 1.7]  [Reference Citation Analysis (0)]
7.  Misra V, Pandey R, Misra SP, Dwivedi M. Helicobacter pylori and gastric cancer: Indian enigma. World J Gastroenterol. 2014;20:1503-1509.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 31]  [Cited by in F6Publishing: 34]  [Article Influence: 3.8]  [Reference Citation Analysis (0)]