Montag, 29. Oktober 2012

Helicobacter pylori (Part II): How to test and to treat?

How to test?

Urea Breath Test (UBT), validated stool antigen test and as a close second validated IgG serology (not useful for follow-up, best test if you use acid-suppressing drugs). 

„Several non-invasive H pylori tests are established in clinical  routine.  The UBT [Urea Breath Test (UBT)] using essentially [13C]urea remains the best test to  diagnose H pylori infection, has a high accuracy and is easy to  perform.76 During recent years new formats of the SAT [stool antigen test] (using  monoclonal antibodies instead of polyclonal antibodies, which  lead to a constant quality of the reagents have been developed.  The two formats available are: (1) laboratory tests (ELISAs) and  (2) rapid in-office tests using an immunochromatographic  technique. A meta-analysis of 22 studies including 2499 patients  showed that laboratory SATs using monoclonal antibodies  have a high accuracy both for initial and post-treatment diagnosis  of H pylori.77 These data have been confirmed by more  recent studies.78 79 In contrast, the rapid in-office tests have a  limited accuracy.80 81  Therefore, when a SAT has to be used the recommendation is  to use an ELISA format with a monoclonal antibody as reagent.“

The Urea Breath Test (UBT) and stool antigen testing are acceptable non-invasive tests for H pylori infection in this setting. For UBT, sensitivity is 88-95% and specificity 95%-100%.4 Stool antigen testing may be somewhat less acceptable to patients in some cultures but is equally valid, with a sensitivity of 94% and a specificity of 92%.5

How to treat?

The standard is triple treatment including PPI(acid inhibition) clarithromycin, and amoxicillin (or metronidazole), but can be further improved. Talk to your gastroenterologist.

 Proton pump inhibitor (PPI)-clarithromycin containing triple therapy without prior susceptibility testing should be abandoned when the clarithromycin resistance rate in the region is over 15-20% 
The use of high-dose (twice a day) PPI increases the efficacy of triple therapy [esomeprazole preferred; perhaps slow phase-out vs rebound-reflux disease?]
Extending the duration of PPI-clarithromycin-containing triple treatment from 7 to 10-14 days improves the eradication success by approximately 5% and may be considered
Certain probiotics and prebiotics show promising results as an adjuvant treatment in reducing side effects [I'd recommend lactoferrin because of its safety]

Against inducing antibiotic resistance: hygiene and sanitation (don’t transfer the resistant germs), 100% compliance if possible, state of the art therapy with high acid suppression (increases specificity for the stomach), watch out for local patterns of resistance.

[1a] Management of Helicobacter pylori infection—the Maastricht IV/Florence consensus report. Malfertheiner et al.

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