Evidence-Based Guidelines for the Treatment of <i>Helicobacter pylori</i> Infection in Korea 2020

Abstract

Helicobacter pylori infection is one of the most common infectious diseases worldwide. Although the prevalence of H. pylori is gradually decreasing, approximately half of the world's population still becomes infected with this disease. H. pylori is responsible for substantial gastrointestinal morbidity worldwide, with a high disease burden. It is the most common cause of gastric and duodenal ulcers and gastric cancer. Since the revision of the H. pylori clinical practice guidelines in 2013 in Korea, the eradication rate of H. pylori has gradually decreased with the use of a clarithromycin-based triple therapy for 7 days. According to a nationwide randomized controlled study conducted by the Korean College of Helicobacter and Upper Gastrointestinal Research released in 2018, the intention-to-treat eradication rate was only 63.9%, which was mostly due to increased antimicrobial resistance, especially from clarithromycin. The clinical practice guidelines for the treatment of H. pylori were updated according to evidence-based medicine from a meta-analysis conducted on a target group receiving the latest level of eradication therapy. The draft recommendations developed based on the meta-analysis were finalized after an expert consensus on three recommendations regarding the indication for treatment and eight recommendations for the treatment itself. These guidelines were designed to provide clinical evidence for the treatment (including primary care treatment) of H. pylori infection to patients, nurses, medical school students, policymakers, and clinicians. These may differ from current medical insurance standards and will be revised if more evidence emerges in the future.

Second-Line Bismuth-Containing Quadruple Therapy for Helicobacterpylori Infection: A 12-Year Study of Annual Eradication Rates

“…Another study from 2006 to 2015 reported a similar result [ 21 ], but the number of subjects was relatively small (231 subjects). Interestingly, although there is a difference in the rate of antibiotic resistance in various geographic areas, BQT shows successful results and is recommended as a first- or second-line therapy in most areas [ 5 , 6 , 7 , 8 , 9 , 22 ]. Recent European data (Hp-EuReg) also showed similar results to this study in second-line BQT [ 23 , 24 ].…”

“…The 2013 Korean guideline recommends a duration of approximately 7 to 14 days for second-line BQT [ 7 ]. The more recently published 2020 Korean guideline recommends BQT for 14 days as a second-line therapy [ 8 ], but this recommendation has not yet been widely accepted in clinical settings. Considering the potential for adverse events and difficulties with compliance, some clinicians prefer a 7-day regimen.…”

“…These data represent the real-world clinical situation in which the recently emerging clarithromycin resistance test cannot be performed. A recent meta-analysis of 26 studies from Korea found that pooled eradication rates of first-line STT were 71.6% in ITT analysis and 79.6% in PP analysis [ 8 ]. Applying our data here, the expected eradication success rates are 86.5% in ITT analysis and 98.7% in PP analysis, assuming that H. pylori -positive individuals receive first-line STT and second-line BQT if necessary.…”

“…Generally, proton pump inhibitor (PPI)-based standard triple therapy (STT) of PPI, amoxicillin and clarithromycin has been commonly recommended as the first-choice treatment. If it fails, bismuth-containing quadruple therapy (BQT) consisting of PPI, bismuth, metronidazole and tetracycline is recommended as a second-line therapy [ 5 , 6 , 7 , 8 , 9 ]. In Korea, recent reported data of H. pylori resistance rates against clarithromycin, metronidazole, amoxicillin, tetracycline and levofloxacin were 17.8~45.9%, 29.5~43.2%, 8.1~9.5%, 0~16.2% and 37.0~62.2%, respectively [ 10 , 11 ], and there has been a decrease in efficacy of first-line STT due to an increased resistance to clarithromycin [ 12 ].…”

Diagnosis of Helicobacter pylori Infection and Recent Advances

“…In China, primary resistance rate to clarithromycin was 20-50% [24]. The resistance rate of clarithromycin in Korea was 17.8-31.0% [25], and the clarithromycin resistance rate in Japan was 38.5% [26]. Resistance to clarithromycin was significantly associated with failure of clarithromycin-containing regimens.…”