What Would the Screen-and-Treat Strategy for Helicobacter pylori Mean in Terms of Antibiotic Consumption?

Abstract

Several guidelines recommend the screen-and-treat strategy, i.e. active search for the presence of Helicobacter pylori infection and its eradication to prevent the possibility of gastric cancer. It is thought that a relatively short duration antibiotic regimen given once in a lifetime would not significantly increase overall antibiotic consumption. However, this would mean offering antibiotic treatment to the majority of the population in countries with the biggest burden of gastric cancer who would, therefore, have the greatest benefit from such a strategy. So far, no country has implemented an eradication strategy. With an example based on the current situation in Latvia, we have estimated the increase in antibiotic consumption if the screen-and-treat strategy was applied. Depending on the scenario that might be chosen, clarithromycin consumption would increase up to sixfold, and amoxicillin consumption would double if the recommendations of the current guideline in the local circumstances was applied. It appears that an increase in commonly used antibiotic consumption cannot be justified from the viewpoint of antibiotic stewardship policies. Solutions to this problem could be the use of antibiotics that are not required for treating life-threatening diseases or more narrow selection of the target group, e.g. young people before family planning to avoid transmission to offspring. Additional costs related to the increase in resistome should be considered for future cost-effectiveness modelling of the screen-and-treat strategy.

Randomised clinical trial: comparison of efficacy and adverse effects of a standard triple clarithromycin-containing regimen with high-dose amoxicillin and bismuth therapy in Helicobacter pylori eradication

“…As clarithromycin is widely used to treat a variety of life-threatening diseases and can provoke bacterial resistance, it would be advisable to consider another treatment regimen for eradicating H. pylori infection without clarithromycin. Despite its low resistance rates in Latvia (Leja and Dumpis 2020), it is important to be cautious and avoid consumption of clarithromycin whenever possible. In the Review on Antimicrobial Resistance, chaired by Jim O’Neill, the rapid growth of antimicrobial resistance was discussed.…”

“…This is justified because the bacterium is a recognised group I carcinogen by the International Agency for Research on Cancer of the WHO (IARC Working Group on the Evaluation of Carcinogenic Risks to Humans 1994;IARC 2011). Considering half of the global population is H. pylori-infected, the introduction of the search-and-treat programs globally is likely leading to increased consumption of antibiotics (Leja and Dumpis 2020); therefore, the choice of a treatment regimen with higher efficacy and fewer adverse effects is critical.…”

Management ofHelicobacter pyloriinfection: the Maastricht VI/Florence consensus report

“…For successful implementation of the population-based H. pylori search-and-treat programmes, selection of the optimal first-line eradication regimen that is highly efficacious and affordable and that can at the same time minimise the potential antibiotic resistance development is a prerequisite. Considering that the global application of the H. pylori test and treat strategy will unequivocally lead to increased consumption of antibiotics, as estimated in Latvia,379 it is important that the treatment programmes are adapted relative to country/region-specific resistance patterns wherever possible. For example, the choice of antibiotic combinations should avoid, if possible, products that are essential for the treatment of life-threatening infections in the population (eg, clarithromycin)380 especially in areas of high (>15%) clarithromycin resistance.…”

Lack of significant differences between gastrointestinal tract microbial population structure of Helicobacter pylori‐infected subjects before and 2 years after a single eradication event

“…The estimated level of H pylori infections reaches 80% in a generally healthy population, 12 and the extensive level of infection has encouraged physicians and researchers to discuss and develop a strategy for treatment and management of H pylori infections. Recent published recommendations have suggested to employ the “screen‐and‐treat” strategy for H pylori infection in healthy asymptomatic adults from high‐risk areas, 4,13 but they are accompanied by concern that such actions might lead to high antibiotic consumption in the general population and subsequent increased antibiotic resistance of microorganisms other than H pylori 14,15 . As endorsed by the Maastricht V/Florence Consensus report, 4 standard H pylori eradication therapy in geographical areas with low rates of resistance to clarithromycin (<15%) consists of a combination of a proton‐pump inhibitor with clarithromycin, amoxicillin, or metronidazole for 10‐14 days.…”