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Maastricht guidelines for management of HP infection

Clinical Question:
What is the best approach to managing patients with Helicobacter pylori infection?

Bottom Line:
The best approaches to managing Helicobacter pylori (HP) include a stool antigen test for diagnosis; a test-and-treat strategy for uncomplicated dyspepsia in young patients when HP infection is common; and the use of omeprazole-amoxicillin-clarithromycin or quadruple therapy, depending on clarithromycin resistance, to eradicate HP. (LOE = 1a-)

Reference:
Malfertheiner P, Megraud F, O'Morain CA, et al, for the European Helicobacter Study Group. Management of Helicobacter pylori infection -- the Maastricht IV / Florence consensus report. Gut 2012;61(5):646-664.  [PMID:22491499]

Study Design:
Practice guideline

Funding:
Government

Setting:
Various (guideline)

Synopsis:
The Maastricht guidelines are widely considered to be the best summary of the evidence regarding the diagnosis and treatment of HP infection. Workgroups systematically reviewed the literature, made recommendations graded by strength of evidence, and voted on adoption of the final result. The major limitation is that they do not clearly distinguish between patient-oriented and disease-oriented outcomes, something we know is important. For example, recommendations related to diagnostic accuracy alone or to preparation for a test received "A" recommendations. Nevertheless, there are some useful recommendations that may differ from the current practice of most physicians: (1) A urea breath test or stool antigen test are recommended for diagnosis; if the patient is taking a proton pump inhibitor, discontinue it for 2 weeks. Only use IgG serology if the test has been validated and found to be accurate. (2) HP eradication provides some benefit to patients with functional dyspepsia (number needed to treat = 12), but not to patients with reflux disease. (3) A test-and-treat strategy for uncomplicated dyspepsia is recommended when the prevalence of HP infection is at least 20%. (4) Test for HP infection in patients with a history of ulcer, and consider it in a patient embarking on long-term NSAID or aspirin therapy. (5) If clarithromycin resistance is less than 15% to 20%, use omeprazole-amoxicillin-clarithromycin for 7 to 14 days (about 5% better eradication with longer course). (6) If clarithromycin resistance is high, use bismuth containing quadruple therapy or sequential therapy; levofloxacin containing triple therapy is another option.

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