Management Strategies for Helicobacter pylori-Application of the Stewardship Principles

The management strategies for Helicobacter pylori treatment are still diverse, especially because of the unequal availability of the drugs needed. In addition, the development of resistance to some antibiotics leads to unsatisfactory results. The role of H. pylori in gastric cancer, which allows the possibility of prevention in the general population by eradicating the bacteria, is a stimulus to have well-established regimens. This article presents the antimicrobial stewardship principles that can guarantee appropriate treatment. The optimization of the clarithromycin-based triple therapy includes antimicrobial susceptibility testing for clarithromycin, a higher dose of amoxicillin than in the original regimen, more than twice a day, and a proton pump inhibitor (PPI) like rabeprazole or esomeprazole, all administered for 2 weeks. The other regimen often used, the bismuth quadruple therapy, is optimal with the 3-in-1 capsule and a standard or high dose of PPI. In all cases, an eradication control must be performed after 4 to 6 weeks. The so-called concomitant treatment does not meet stewardship principles. The availability of Potassium-Competitive Acid Blockers (P-CABs) in some countries could allow the use of a dual therapy with only amoxicillin, but it must be confirmed by proper trials in Western countries.