DOI: 10.1111/hel.

12519

REVIEW ARTICLE

Treatment of Helicobacter pylori infection in 2018

Neil R. O’Morain1 | Maria P. Dore2 | Anthony J. P. O’Connor1 | Javier P. Gisbert3 | 

Colm A. O’Morain1

1
Department of Gastroenterology &
Clinical Medicine, Tallaght University Abstract
Hospital, Trinity College Dublin, Dublin, Treatment options for the eradication of Helicobacter pylori continue to evolve. There
Ireland
2
have been many guidelines for H. pylori treatment published, which may lead to some
Department of Medical, Surgical and
Experimental Science, University of Sassari, confusion. However, most are in agreement with the most recent iteration of the
Sassari, Italy
Maastricht treatment guidelines. Triple therapy is still the most frequently used
3
Gastroenterology Unit, Hospital
treatment, especially in areas of low clarithromycin resistance. Its best results are
Universitario de La Princesa, Instituto
de Investigación Sanitaria Princesa achieved when taken for a minimum of 10 days and with high-­dose acid suppression.
(IIS-IP), Universidad Autónoma de
Quadruple therapy is gaining in popularity particularly in areas with increasing resist-
Madrid, Centro de Investigación Biomédica
en Red de Enfermedades Hepáticas y ance to standard triple therapy. Whether three antibiotics, or bismuth and two anti-
Digestivas (CIBEREHD), Madrid, Spain
biotics are used, excellent eradication rates are achieved, albeit with increased side
Correspondence effects. Levofloxacin second-­line therapy is widely used; however bismuth, when
Neil O’Morain, Department of
available, is an increasingly successful option. Sequential therapy is challenging in
Gastroenterology & Clinical Medicine,
Tallaght University Hospital/Trinity College terms of compliance and is no longer recommended. This past year witnessed a no-
Dublin, Dublin 24, Ireland.
table increase in the number of studies based on antimicrobial susceptibility testing
Email: neilmoran@gmail.com
and tailored eradication therapy, reflecting the role of culture-­guided treatment,
which may well represent the future of H. pylori treatment and prevent the inappro-
priate use of antibiotics.

KEYWORDS
resistance, eradication therapy, tailored therapy, clarithromycin, Bismuth-based quadruple
therapy, standard triple therapy,

1 |  I NTRO D U C TI O N
The treatment of Helicobacter pylori infection continues to evolve and
remains a topical global research interest.1 Triple therapy has been
modified in that it is now recommended to use double-­dose (80 mg)
proton-­pump inhibitor (PPI), quadruple dose (2 g) amoxicillin, and
2,3
clarithromycin (1 g) for at least 10 days, and preferably 14 days.
The substitution of vonoprazan, a novel potassium-­competitive acid
blocker that provides reversible acid suppression by preventing K+
from binding to gastric H+/K+-­ATPase, for PPIs has shown promising
results, however remains to be tested outside Asia.4-7
Quadruple therapy is gaining in popularity particularly in areas
8,9
with increasing resistance to standard triple therapy. Tailored,
culture-­based treatment seems a logical choice and has significant
success.10 However, there is an expense and delay involved, which
limits its universal use at present.
Levofloxacin remains one of the most favored second-­line thera-
pies; however, bismuth, when available, is an increasingly successful
option. Sequential therapy remains in use in areas of high resistance,
but may prove challenging in terms of compliance, and is no longer
recommended.11 Three-­in-­one formulations of bismuth quadruple
therapy (BQT) may improve compliance.12,13 Probiotics appear to
have some effect on H. pylori eradication, as their addition likely im-
proves compliance by reducing the side effects of antibiotics.14 For
example, several meta-­analyses reported a gain of 10%-­14% in the
cure rate from the addition of a probiotic to traditional therapy com-
pared to placebo.14-17
The European Registry on H. pylori management, supported by
the European Helicobacter and Microbiota Study Group (EHMSG),
is an exciting new endeavor which represents an audit process to
ensure that clinical practice is aligned with best standards of care.
There are now over 21 000 entries from 27 European countries and

Helicobacter. 2018;23(Suppl. 1):e12519. wileyonlinelibrary.com/journal/hel © 2018 John Wiley & Sons Ltd  |  1 of 9
https://doi.org/10.1111/hel.12519
 |
2 of 9       O’MORAIN et al.
the Registry promises to provide invaluable information regarding
18
H. pylori treatment across Europe.
2 |  S TA N DA R D TR I PLE TH E R A PY
High-­dose acid suppression and treatment duration of a minimum
of 10 days offer the best conditions for success with triple therapy.
Several studies in the past year have demonstrated the utility of
standard triple therapy in low resistance areas (<20% resistance to
19
clarithromycin). A retrospective study from the New York metro-
politan area reported a cumulative eradication rate of 86% with 10-­
day Omeclamox®-­Pak, a clarithromycin-­based triple therapy with
once daily omeprazole. 20
A study from Syria highlighted insufficient responses to both
clarithromycin and levofloxacin-­based triple therapies with eradica-
tion rates of 35.1% and 29.7%; however, of note, low-­dose (20 mg)
esomeprazole was given. 21 Based on this, Syria likely represents
an area of high resistance. Metronidazole-­
based triple therapy
has demonstrated efficacy in areas of high clarithromycin resis-
tance (eradication rate with metronidazole 94.3% vs clarithromycin
22
72.7%).
Quadruple therapy, comprised of standard triple therapy with
the addition of rifaximin (a nonabsorbable antibiotic), had poor re-
sults with eradication rates of 61% in Spain. 23 Metronidazole contin-
ues to underperform in triple therapy, with eradication rates of 64%
24
in metronidazole-­naive patients. High-­dose metronidazole does
enhance eradication rates however in areas of high metronidazole
resistance, 25 demonstrating that in vitro resistance of metronidazole
does not always correlate to in vivo failure.
Resistance to the commonly used antibiotics is increasing in
certain areas over time, as demonstrated by a retrospective review
from the Netherlands which reported increasing resistance rates for
clarithromycin (9.8%-­18.1%), metronidazole (20.7%-­23.2%), and am-
picillin (6.3%-­10%) over 10 years. 26 A 10-­year follow-­up study from
Italy showed suboptimal eradication rates using amoxicillin and met-
ronidazole, which had not changed significantly (73.5% vs 69.2%) in
27
the past decade. A further study from Italy suggested that while
resistance to the most frequently used antibiotics had increased, it
had likely plateaued over the past number of years. 28 The first sys-
tematic review of primary antibiotic resistance in the Asia-­Pacific re-
gion reported mean resistance rates of 17% for clarithromycin, 18%
for levofloxacin, and 44% for metronidazole. There was, however,
significant heterogeneity in resistance rates across different coun-
tries in the region. 29
There would appear to be a maximal acid-­suppressive effect
with PPI bid dosing in triple therapy. Eradication rates with PPI tid
dosing compared to PPI bid dosing in standard triple therapy were
not improved.30 Reports of increasing resistance to the components
of standard triple therapy have led to the development of alterna-
tive treatment regimens and a general shift away from the tradi-
tional treatment protocols, particularly in areas with high antibiotic
resistance.
3 | FLU O RO QU I N O LO N E S
Fluoroquinolone-­
based triple therapy is recommended as stand-
ard salvage treatment following first-­line therapy failure. However,
eradication rates with this regimen vary according to resistance rates
which are increasing with its more widespread use. Studies from
Australia report relative success with this salvage therapy, with erad-
ication rates of 89%-­91%.31,32 A Taiwanese study, however, reported
suboptimal eradication rates (69.2%) with triple therapy compared
to fluoroquinolone-­based quadruple therapy.33 A further study from
Taiwan demonstrated higher eradication rates with levofloxacin-­
based concomitant therapy (96.4%) compared to sequential ther-
apy (81.4%).34 The addition of bismuth to levofloxacin-­based triple
therapy, however, in areas with low levofloxacin resistance does not
confer any further benefit.35
A retrospective study assessing the utility of a moxifloxacin-­
based triple therapy reported eradication rates of 80% following hy-
brid therapy failure.36 Quinolone-­based rescue therapies are more
successful in bismuth-­containing quadruple therapies, with longer
duration (10-­14 days) than 7-­day treatment.37 A meta-­analysis found
levofloxacin-­based triple therapy superior to bismuth-­based quadru-
ple therapy in Europe but equivalent in Asia when used for 10 days.
Compliance was also superior and side effects lesser.38 The choice
of fluoroquinolone to select has become an important question.
The addition of ofloxacin to standard triple therapy has been shown
to augment eradication rates,39 while gemifloxacin was inferior to
clarithromycin-­based therapies.40 A review of levofloxacin-­
based
third-­line therapy over the past decade in Korea found pooled eradi-
cation rates of 71.6% throughout the decade, suggesting no increase
in resistance rates over the past decade.41 A 10-­day triple therapy
containing ilaprazole, levofloxacin, and amoxicillin reported good re-
sults, with an eradication rate of 88.8%.42
4 | B I S M U TH
Bismuth salts exert direct bactericidal effect on H. pylori in a num-
ber of ways: by forming complexes in the bacterial wall and in the
periplasmic space and by adherence of the bacteria to the gas-
tric mucosa. Bismuth also aids ulcer healing by increasing mucosal
protective factors such as prostaglandin, epidermal growth factor,
and bicarbonate secretion.43 In areas with multiresistant strains
of H. pylori and high rates of antibiotic resistance, bismuth rescue
therapy is an effective treatment option, with eradication rates
as high as 97.6%. 8,13,44 BQT is commonly recommended in treat-
ment guidelines as a rescue therapy 2 and as first-­line therapy in
areas of high resistance. The three‐in‐one capsule (Pylera®) has
proven a popular treatment option for patients which may improve
compliance. BQT has been shown to be effective as both a first-­
line and rescue therapy option. 8,12,45-48 A Chinese randomized
controlled trial reported convincing superiority for 10-­day quad-
ruple bismuth-­b ased therapy over 10-­day standard triple therapy
(92.3% vs 63.2%).9
O’MORAIN et al. |
      3 of 9

Modifications to the standard BQT have also been studied this
past year. A trial of 7-­day concomitant quintuple therapy contain-
ing bismuth demonstrated effective eradication rates but with in-
creased side effects.49 The addition of bismuth to standard 7-­day
triple therapy did not substantially increase the eradication rate in one
50
study. A comparison of levofloxacin-­containing triple therapy with
levofloxacin-­containing BQT and standard BQT from Turkey found
containing regimens to be superior.51 An American study
bismuth-­
found modified dual therapy consisting of higher doses of PPI reached
comparative eradication rates with BQT, without significant adverse
effects.52
5 | VO N O PR A Z A N
The utility of vonoprazan, a novel potassium-­competitive acid blocker
that provides reversible acid suppression by preventing K+ from
binding to gastric H+/K+-­ATPase, has been further explored in the
past year. A large Japanese trial comparing vonoprazan vs PPI in first-­
line triple therapy reported a significantly higher eradication rate with
vonoprazan (90.8%) compared to esomeprazole (77.5%) or rabeprazole
53
(68.4%). The eradication rates of vonoprazan with amoxicillin and
clarithromycin in clarithromycin-­resistant patients were 82.9%.6,54
A meta-­analysis of 14 studies with over 14 636 patients found
that the pooled eradication rates of vonoprazan‐containing regi-
mens were higher than that of PPI‐containing regimens when used
as first‐line therapies. Subgroup analysis further indicated the
superiority of vonoprazan in both patients with clarithromycin-­
resistant strains (81.5% vs 40.9%, P < 0.00001) and those with
55
clarithromycin-­susceptible strains (94.9% vs 89.6%, P = 0.006).
A multicentre retrospective study of patients who received
vonoprazan-­based therapy reported an eradication rate of 94.4%
for first-­line therapy, rising to 97.1% for second-­line therapy, with
7
a low level (4.4%) of adverse events reported.
A review with meta-­a nalyses evaluated 10 studies including
10,644 patients. This demonstrated superior eradication rates
(87.9% vs 72.8%) and a comparable tolerability and incidence
of adverse events. 56 A small study assessing regimens includ-
ing vonoprazan for penicillin-­
a llergic patients demonstrated
an eradication rate of 92.9% for patients who received clari-
thromycin‐metronidazole‐vonoprazan which far surpassed the
54.2% achieved by PPI-­b ased therapies. 57 Triple therapy with
vonoprazan, clarithromycin, and metronidazole was well toler-
ated and effective for eradicating H. pylori in patients allergic to
penicillin. 58
Safety of new medication is always a concern. One study assessing
vonoprazan triple therapy in children found adverse effects (rash/GI
disturbance) in 21.1%.59 Vonoprazan represents one option to combat
decreasing eradication rates for clarithromycin-­based triple therapy;
however, there is concern this may not be adequate for countries
with higher rates of clarithromycin resistance.60 An important caveat
to these promising results is that in many of the head-­to-­head trials,
vonoprazan was compared to single dosing PPI which does not re-
flect the optimum use of this treatment. The efficacy of vonoprazan
in Asia may not translate into the West, given the genetic variability in
CYP2C19 metabolism in the different patient groups. A summary of
studies comparing vonoprazan and PPI eradication rates is presented
below (Table 1).
6 | CU LT U R E- ­G U I D E D TR E ATM E NT
Culture-­guided treatment has been recommended in the Maastricht
V consensus guidelines after a failed second-­line treatment. However,
in the era of increasing antibiotic resistance, it may be more logical to
prescribe according to culture and antimicrobial susceptibility test-
ing (AST) already as first line. This would decrease the misuse of anti-
biotics in H. pylori treatment. Culture, AST, and genotypic resistance

TA B L E   1   Eradication rates with vonoprazan compared with proton-­pump inhibitors (PPIs)

Eradication rate Eradication Second-­line eradication

Author Country N Study design Formulation vonoprazan (%) rate PPI (%) with vonoprazan (%)

Ozaki et al4 Japan 1709 Prospective Triple with 90.8 77.5 esomepra- –
AMO, CLA zole
68.4
rabeprazole
Sue et al6 Japan 147 Prospective Triple with 88.9 86.7 –
AMO, CLA
Dong et al55 Japan 14 636 Meta-­analysis 89 74.2 89.3
7
Tanabe et al Japan 799 Retrospective Triple with 94.4 97.1
AMO, CLA
Jung et al56 Korea 10 644 Meta-­analysis 87.9 72.8
Ribaldone Italy 66 Prospective Triple with 69.2
et al94 AMO, MET
Dacoll et al97 Uruguay 41 Prospective Triple with 89.5
AMO, MET

AMO, amoxicillin; CLA, clarithromycin; MET, metronidazole.

 |
4 of 9       O’MORAIN et al.

patterns are increasingly employed to guide the selection of antibi-

CLA + MET
otics, particularly in regions with high resistance rates. Antibiotic re-
sistance varies significantly across the globe (Table 2). A prospective
Greek study enrolled 51 patients for genotypic resistance-­guided
7-­
day triple therapy. Genotyping of clarithromycin, levofloxacin,

CLA + AMO
and rifabutin was performed. Following tailored triple therapy, the
pooled eradication rate was 97.8%. There was no significant differ-
ence in eradication rates between treatment-­naive and treatment-­
experienced groups.61 This, however, is at odds with a Spanish study
which found significantly higher eradication rates (83% vs 33%) in
culture-­guided therapy in treatment-­naïve patients.10

TET%

3.9
An Italian study comparing sequential and bismuth-­based ther-

4
apy did not find that the pattern of bacterial resistance significantly
affected eradication rates. Dual resistance to clarithromycin and

33.3
amoxicillin did, however, lower eradication rates in both treatment

RIF
strategies.62 Susceptibility-­
based therapy is especially important
to guide tailored treatment after failure of standard empiric thera-
pies. An American retrospective cohort study analyzed 49 patients

MET

63.8
23.2
45.3

31.1
27.2
44
who had failed at least three empiric treatment regimens. Culture-­

27
positive H. pylori was confirmed in 82% (n = 42), of whom 60%
(n = 24) achieved successful eradication following tailored treat-

LEVO%
ment, thus highlighting the difficulties in achieving eradication even

10-­12
12.3

38.7
29.7
in the setting of AST.63

28
18
Indeed, third-­line culture-­guided eradication therapy often fails.

AMO, amoxicillin; CLA, clarithromycin; LEVO, levofloxacin; MET, metronidazole; RIF, rifampicin; TET, tetracycline.
Multidrug (>3) resistance rates have been found in 15%-­31% of pa-
AMO%

tients undergoing third-­line therapy.10 Age >50 years was the only

TA B L E   2   Primary resistance patterns of Helicobacter pylori according to antibiotics and country

3.1
discerning factor associated with resistance to three or more anti-
biotics, most likely related to lifetime exposure.64 However, culture-­ 3
guided first-­line treatment is seldom.
CLA%

17-­19
12.3

22.4
35.6

28.9
25.9
18.1
17.8

17

7 |  PRO B I OTI C S

322
707
1424

162
155

217

The interest in probiotic therapy as an adjunct to eradication therapy 514

N

has certainly increased over the past year with the number of
publications rising significantly. As the effective treatment duration
increases, there is a concern regarding antimicrobial side effects. In
Systematic Review

one recent study, the addition of a probiotic was shown to reduce

Retrospective
Study design

the frequency of adverse events from 28.2% in the nonprobiotic

Prospective

Prospective

Prospective
Prospective

Prospective

Prospective

group to 12.2%.65
Review

A meta-­
analysis reported that the addition of a probiotic to
bismuth-­based quadruple therapy increases the eradication rate by
approximately 10%.14 A systematic review assessed the efficacy of
probiotics as monotherapy. While probiotics were found to be su-
Netherlands

Asia-­Pacific

perior to placebo, the pooled eradication rate from the 11 included

Germany
Country

Greece

Austria
Taiwan

studies was only 14%.66 One study evaluated the anti‐H. pylori activ-
China
Spain
Italy

ity of seven Lactobacillus delbrueckii subsp. bulgaricus (GLB) strains.67

The GLB strains were found to produce heat‐stable bacteriocin‐like
inhibitory substances that had a strong anti‐H. pylori activity, ren-
Macías-­García

Bilgilier et al100
Miehlke et al12

Georgopoulos
Fiorini et al28

dering them valuable probiotics in the control of H. pylori infec-

26
Ruiter et al

29

101
Wu et al35

tion. Lactobacillus reuteri (2 × 108 CFU L. reuteri DSM 17938 plus

Kuo et al

Hu et al
et al98
Author

et al99

2 × 108 CFU L. reuteri ATCC PTA 6475) 7 times per day or match-

ing placebo plus 20 mg pantoprazole bid for 4 weeks was used for
O’MORAIN et al.
H. pylori eradication in a double-­blind placebo-­controlled random-
ized 2-­site study. The cure rates per protocol were 3/24 (12.5%; 95%
CI 2.6%-­32%) with L. reuteri vs 1/24 (4.1%) with placebo.17
One study aimed to identify the best probiotic supplementation
in triple therapy for a pediatric population. In total, 29 trials were
reviewed. Lactobacillus casei was identified as the best probiotic for
H. pylori eradication rates and multistrain of Lactobacillus acidophi-
lus and Lactobacillus rhamnosus for total side effects. Another study
suggested the combination of Bacillus mesentericus, Clostridium bu-
tyricum, and Streptococcus faecalis as the optimal probiotic regime
for reducing side effects and improving eradication rates when sup-
plementing 14-­day triple therapy.68 Current meta-­analyses suggest
that probiotics as an adjunctive therapy increase the cure rate by
14-17
approximately 10%-­14%. In addition, probiotics are likely to im-
prove compliance and therefore improve eradication rates of triple
therapy. However, the potential benefit of adding probiotics to more
recent and effective combinations (such as concomitant or BQT reg-
imens) has yet to be proven.
8 | S EQU E NTI A L A N D CO N CO M ITA NT
TH E R A PY
Most clinical guidelines recommend BQT as rescue treatment for
H. pylori eradication failure. However, high cost, side effects, and low
compliance rates are major drawbacks to its routine use. Ten-­day
sequential therapy is more efficient than BQT (Pylera®) in terms of
69
H. pylori eradication in high resistance areas. Neither an extension
to the duration of sequential treatment to 14 days nor the addition
70
of bismuth improved eradication rates.
In Korea, where high levels of clarithromycin resistance have
been reported, 10-­day concomitant therapy achieved eradication
rates in excess of 95% in per protocol analysis71 and proved superior
72
to sequential therapy in terms of efficacy. A systematic review and
meta-­analysis compared the efficacy and safety of concomitant and
sequential therapy. In this review, the efficacy of concomitant ther-
apy was found to be duration dependent, with 10-­day concomitant
therapy being the most efficacious therapy and superior to 10-­day
sequential therapy. Concomitant therapy also showed superior ef-
ficacy for metronidazole-­resistant strains and metronidazole plus
clarithromycin-­resistant strains.73 A study from Israel suggested bet-
ter compliance and fewer adverse effects with sequential treatment
when used as a second-­line regimen, which they found noninferior
to bismuth-­based quadruple therapy.74
A 5-­year prospective review in Italy assessed antimicrobial resis-
tance to clarithromycin, metronidazole, and levofloxacin before giv-
ing 10-­day sequential therapy as first-­line therapy. Even in patients
with dual resistance, 10-­day sequential therapy was 83.1% effective
11
in treating the underlying H. pylori infection. A Turkish study high-
lighted the role for 5 + 5 clarithromycin-­based sequential therapies
in areas with low clarithromycin resistance rates, which was found to
75
be superior to 14-­day triple therapy and BQT.
|
      5 of 9
9 | H Y B R I D TH E R A PY
Hybrid therapy initially emerged as a promising alternative approach
to H. pylori eradication, particularly in areas with high antibiotic re-
sistance rates. In the past year, however, interest in this treatment
paradigm waned. One study assessed hybrid therapy consisting
of 14-­day therapy with a PPI and amoxicillin, with the addition of
clarithromycin and metronidazole for the final 7 days, and demon-
strated eradication rates >90% even in the presence of significant
antibiotic resistance.19 Dual antibiotic resistance, however, signifi-
cantly reduced eradication rates. Another study compared hybrid
therapy with sequential therapy in an Indian cohort and reported
significantly higher eradication rates (93% vs 81.5%) and comparable
compliance rates and side effects.76
10 | FAC TO R S O F TR E ATM E NT FA I LU R E
A number of studies have sought to identify factors associated with
treatment failure. A retrospective study from Spain suggests previ-
ous use of macrolides correlates with a low H. pylori eradication rate
with triple and concomitant clarithromycin‐containing regimens.77
Repeated use of previously failed treatment combinations also con-
tributes to poor eradication rates,78 highlighting the importance of
efficient documentation of treatment histories. Treatment failure
occurred more frequently in patients with 25-­OH vitamin D defi-
ciency,79 whereas supplementing eradication therapy with vitamin
C and E has no effect.80 A Japanese study found lower eradication
rates with standard triple therapy in younger cohorts, perhaps re-
flecting poorer compliance.81
11 | N OV E L TH E R A PI E S
There have been several studies in the past year evaluating novel
treatment options for H. pylori, with mixed results. An intervo-
lin (antitumour) derivative, AS-­1934, was found to have selective
anti‐H. pylori activity, including against antibiotic‐resistant strains,
without any effect on intestinal bacteria. In mouse models, this
outperformed conventional triple therapy, suggesting a possible fu-
ture treatment option.82 A Korean group evaluated the efficacy of
gentamicin-­intercalated smectite hybrid (S-­GEN)-­based treatment
regimens in a murine model of H. pylori infection, showing positive
results83; however, more extensive studies are required.
A study from Africa suggests that the methanol extract of
Bryophyllum pinnatum, a plant known for its antioxidant properties,
could inhibit H. pylori growth, and may also act as an antioxidant to
protect gastric mucosa against reactive oxygen species.84 A study
from Iran demonstrated reduced endoscopic scores of inflamma-
tion and increased H. pylori eradication rates with the addition
of curcumin (a turmeric extract) to standard triple therapy.85 An
Egyptian group evaluated eradication rates with nitazoxanide, an
anti-­infective drug with demonstrated activity against protozoa and
 |
6 of 9       O’MORAIN et al.
anaerobic bacteria but also H. pylori. When nitazoxanide replaced
metronidazole in triple therapy, the reported eradication rates were
94.6% compared with 60.6%.86
A review of 18 studies assessing the results of quadruple ther-
apy trials containing bismuth and high dose of furazolidone in Iran
found a pooled eradication rate of 87%, suggesting this remains
an underutilized eradication therapy. 87 A meta-­analysis of 18 stud-
ies reported high eradication rates when furazolidone was used
in conjunction with standard triple therapy, metronidazole, or
bismuth. 88
As resistance rates to conventional eradication therapies in-
crease, there has been a renewed focus on BQT. Access to bis-
muth, however, remains an issue in many countries. An open-­label
randomized phase IV trial compared berberine, a natural alkaloid,
with bismuth in quadruple therapy with comparable eradication
rates (90.1% and 86.4%). Berberine-­based quadruple therapy may
therefore represent a treatment option in areas with limited access
to bismuth. 89 Triple therapy containing polaprezinc (a mucosal pro-
tective chelate compound of zinc and l-­c arnosine) was analyzed
in an open-­label prospective trial in 11 cities in China. Eradication
rates with standard triple therapy were notably higher with po-
laprezinc (83.3% vs 61.4%) without any serious adverse effects
reported.90
12 |  G U I D E LI N E S
The past year has seen several national and society guidelines up-
dated. The fifth Chinese national consensus report,91 a Catalan
position paper,92 the first Irish consensus statements,93 local man-
agement in Piedmont (Italy),94 and updated American College of
Gastroenterology clinical guidelines95 were all published in the past
year. The proliferation of national and regional guidelines reflects
the emphasis Maastricht V guidelines have put on the importance
of local resistance patterns. Treatment options based on local resist-
ance patterns taking antibiotic susceptibility into account remain the
goal. 2
13  |  R EG I S TR I E S
The European Registry on H. pylori management, supported by the
EHMSG, is an exciting new endeavor which represents an audit
process to ensure clinical practice is aligned with best standards
of care. There are now over 21 000 entries from 27 participating
European countries and the Registry promises to provide invalu-
able information regarding H. pylori treatment across Europe.18
The Registry has received international recognition and was
awarded the National Scholar Award by the United European
Gastroenterology. This year, published data from the Registry
regarding Slovenia demonstrate low resistance to clarithromycin,
where triple therapy with PPI plus two antibiotics reaches eradica-
tion rates >85%.96
14 | CO N C LU S I O N
The treatment of H. pylori remains a much studied and debated
topic. Antibiotic resistance is a stumbling block to current therapies
and prevents universal consensus on best treatment options. As
treatments remain complex, compliance is an ongoing issue. Culture-­
based treatment would overcome many of these obstacles and ap-
pears logical, but is not currently universally applied.
D I S C LO S U R E S O F I N T E R E S T S
The authors have no interests to disclose.
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How to cite this article: O’Morain NR, Dore MP, O’Connor
AJP, Gisbert JP, O’Morain CA. Treatment of Helicobacter
pylori infection in 2018. Helicobacter.
2018;23(Suppl. 1):e12519. https://doi.org/10.1111/hel.12519