ObjectiveThe best approach for Helicobacter pylori management remains unclear. An audit process is essential to ensure clinical practice is aligned with best standards of care.DesignInternational multicentre prospective non-interventional registry starting in 2013 aimed to evaluate the decisions and outcomes in H. pylori management by European gastroenterologists. Patients were registered in an e-CRF by AEG-REDCap. Variables included demographics, previous eradication attempts, prescribed treatment, adverse events and outcomes. Data monitoring was performed to ensure data quality. Time-trend and geographical analyses were performed.Results30 394 patients from 27 European countries were evaluated and 21 533 (78%) first-line empirical H. pylori treatments were included for analysis. Pretreatment resistance rates were 23% to clarithromycin, 32% to metronidazole and 13% to both. Triple therapy with amoxicillin and clarithromycin was most commonly prescribed (39%), achieving 81.5% modified intention-to-treat eradication rate. Over 90% eradication was obtained only with 10-day bismuth quadruple or 14-day concomitant treatments. Longer treatment duration, higher acid inhibition and compliance were associated with higher eradication rates. Time-trend analysis showed a region-dependent shift in prescriptions including abandoning triple therapies, using higher acid-inhibition and longer treatments, which was associated with an overall effectiveness increase (84%–90%).ConclusionManagement of H. pylori infection by European gastroenterologists is heterogeneous, suboptimal and discrepant with current recommendations. Only quadruple therapies lasting at least 10 days are able to achieve over 90% eradication rates. European recommendations are being slowly and heterogeneously incorporated into routine clinical practice, which was associated with a corresponding increase in effectiveness.

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Brglez Jurecic 14 | José María Huguet 15 | Noelia Alcaide 16 | Irina Voynovan 17 | José María Botargues Bote 18 | Inés Modolell 19 | Jorge Pérez Lasala 20 | Inés Ariño 21 | Laimas Jonaitis 22 | Manuel Dominguez-Cajal 23 | György Buzas 24 | Frode Lerang 25 | Monica Perona 26 | Dmitry Bordin 17 | Toni Axon 27 | Antonio Gasbarrini 28 | Ricardo Marcos Pinto 29 | Yaron Niv 30 | Limas Kupcinskas 22 | Ante Tonkic 31 | Marcis Leja 32 | Theodore Rokkas 33 | Lyudmila Boyanova 34 | Oleg Shvets 35 | Marino Venerito 36 | Peter Bytzer 37 | Adrian Goldis 38 | Ilkay Simsek 39 | Vincent Lamy 40 | Krzysztof Przytulski 41 | Lumír Kunovský 42 | Lisette Capelle 43 | Tomica Milosavljevic 44 | María Caldas 1 | Ana Garre 1 | Francis Mégraud 45 | Colm O'Morain 46 | Javier P. Gisbert 1 | On behalf of the Hp-EuReg Investigators Abstract Background: Experience in Helicobacter pylori eradication treatment of patients allergic to penicillin is very scarce. A triple combination with a PPI, clarithromycin (C), and metronidazole (M) is often prescribed as the first option, although more recently the use of a quadruple therapy with PPI, bismuth (B), tetracycline (T), and M has been recommended. Aim: To evaluate the efficacy and safety of first-line and rescue treatments in patients allergic to penicillin in the "European Registry of H pylori management" (Hp-EuReg). Methods: A systematic prospective registry of the clinical practice of European gastroenterologists (27 countries, 300 investigators) on the management of H pylori infection. An e-CRF was created on AEG-REDCap. Patients with penicillin allergy were analyzed until June 2019. Results: One-thousand eighty-four patients allergic to penicillin were analyzed. The Additional supporting information may be found online in the Supporting Information section. How to cite this article: Nyssen OP, Perez-Aisa Á, Tepes B, et al; On behalf of the Hp-EuReg Investigators. Helicobacter pylori first-line and rescue treatments in patients allergic to penicillin: Experience from the European Registry on H pylori management (Hp-EuReg). Helicobacter. 2020;25:e12686.

Helicobacter pylori eradication has become increasingly challenging. We focused on recent data about rifamycin resistance and rifamycin-containing regimens. Rifampin (rifampicin) resistance rates were <1–18.8% (often ≤7%), while those to rifabutin were 0–<4%. To detect rifabutin resistance by rifampin, 4 mg/l breakpoint was suggested. Eradication success by rifaximin-based regimens was disappointing (<62%), while that of rifabutin-containing regimens was 54.5–>96%, reaching >81% in four studies. Some newer rifamycin analogs like TNP-2092 need further investigation. Briefly, although rifabutin-based regimens carry a risk of adverse effects or increasing mycobacterial resistance, they may be a rational choice for some multidrug-resistant H. pylori strains and as a third-line eradication therapy. Bismuth addition to rifabutin-based therapy and combined rifabutin-containing capsules (Talicia) are promising treatment options.

The aim of this study was to assess the primary and combined resistances of Helicobacter pylori isolates obtained from paediatric patients in 2000-2001 to seven antimicrobial agents. Resistance rates of pre-treatment isolates from 115 children were investigated by the limited agar dilution method alone and by the E-test. The cut-off concentrations for resistance were: metronidazole >8 mg/L, clarithromycin and azithromycin >1 mg/L, clindamycin >4 mg/L, amoxicillin >0.5 mg/L, tetracycline >4 mg/L and ciprofloxacin >1 mg/L. Primary resistance rates were: metronidazole 15.8%, clarithromycin 12.4%, azithromycin 14.6%, clindamycin 20.0%, amoxicillin 0%, metronidazole + clarithromycin 4.5%, ciprofloxacin 6.0%, metronidazole + clarithromycin + ciprofloxacin 1.2%, tetracycline 3.1% and metronidazole + ciprofloxacin 1.2%. There were no significant age (1-9 years versus 10-18 years) or gender differences. Prevalence of both macrolideresistant and intermediately susceptible strains was 21.9% for azithromycin and 15.9% for clarithromycin. Of 18 metronidazole-resistant isolates, 77.8% exhibited a metronidazole MIC >32 mg/L. H. pylori resistance rates to metronidazole, clarithromycin and both agents were relatively low in Bulgarian children. However, resistance was found to all drugs tested except for amoxicillin. The consumption of newer macrolides and tetracyclines could be related to the prevalence of resistance to the corresponding agents. There were no significant differences in primary resistance rates of H. pylori to antimicrobial agents between children and adults except for metronidazole. Multi-drug resistance to newer macrolides, metronidazole and ciprofloxacin in association with a slightly elevated amoxicillin MIC (0.38 mg/L) was detected in one strain.