“Helicobacter pylori treatment guideline: An Indian perspective”: Letter to the editor

Abstract

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.

TO THE EDITOR

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.