The principal effect of Helicobacter pylori infection is lifelong chronic gastritis, affecting up to 20% of younger adults but 50% to 80% of adults born in resource-rich countries before 1950.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of H pylori eradication treatment in people with a confirmed duodenal ulcer, a confirmed gastric ulcer, confirmed gastro-oesophageal reflux disease (GORD), confirmed non-ulcer dyspepsia, uninvestigated dyspepsia, localised B cell lymphoma of the stomach, and non-steroidal anti-inflammatory drug (NSAID)-related peptic ulcers? What are the effects of H pylori eradication treatment for preventing NSAID-related peptic ulcers in people with or without previous ulcers or dyspepsia? What are the effects of H pylori eradication treatment on the risk of developing gastric cancer? Do H pylori eradication treatments differ in their effects? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 58 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: effects of H pylori eradication in different populations; relative effects of triple regimens, quadruple regimens, and sequential regimens.
The principal effect of Helicobacter pylori infection is lifelong chronic gastritis, affecting up to 20% of younger adults but 50% to 80% of adults born before 1950 in resource-rich countries.
H pylori infection can be identified indirectly by the C13 urea breath test and stool antigen tests, which are more accurate than serology.Transmission and prevalence rates are higher in areas of childhood poverty. Adult reinfection rates are less than 1% a year.In people with H pylori infection, about 15% will develop a peptic ulcer and 1% will develop gastric cancer during their lifetime.
Eradication of H pylori makes healing of duodenal ulcers more likely and reduces the risk of bleeding with gastric and duodenal ulcers, either alone or when added to antisecretory drug treatment. Eradication also greatly reduces the risk of recurrence of a duodenal ulcer.
Eradication reduces recurrence after healing of a gastric ulcer; however, we don't know whether it increases healing of gastric ulcers.Eradication of H pylori may reduce the risk of NSAID-related ulcers in people without previous ulcers; however, we don't know whether it reduces NSAID-related ulcers or bleeding in people with previous ulcers.
In areas of low prevalence of H pylori, few ulcers are caused by H pylori infection. Eradication may be less effective in preventing ulcers in these areas compared with higher-prevalence areas.
Eradication of H pylori reduces symptoms of dyspepsia, but not of GORD.
Eradicating H pylori has been shown to reduce dyspeptic symptoms in people with non-ulcer dyspepsia or uninvestigated dyspepsia compared with placebo.
Despite the association between
H pylori infection and gastric cancer, no studies have shown a reduced risk after eradication treatment.
Gastric B cell lymphoma lesions may regress after H pylori eradication, but we don't know this for sure.
Quadruple and triple regimens seem equally effective at eradicating H pylori as first-line treatments. Quadruple regimens may be more effective as second-line treatment than triple regimens when a first-line triple regimen has failed to eradicate the infection. However, the evidence is limited in that, in comparisons of second-line quadruple versus triple regimens, most triple regimens did not contain a nitroimidazole.
Ten-day sequential therapy may be more effective at eradicating H pylori than a 7-day triple regimen.
Nitroimidazole-based triple regimens and amoxicillin-based triple regimens seem equally effective at eradicating H pylori. High-dose clarithromycin within an amoxicillin-based triple regimen seems more effective at eradicating H pylori than low-dose clarithromycin. However, the dose of clarithromycin within a nitroimidazole-based triple regimen does not seem to have an effect on eradication rates.
Triple regimens using different proton pump inhibitors seem equally effective at eradicating H pylori.
Pre-treatment with a proton pump inhibitor before triple regimen does not seem to increase H pylori eradication rates compared with no pre-treatment.
Two-week triple proton pump inhibitor regimens may be more effective than 1-week regimens for eradicating H pylori.
Lower eradication rates are achieved in people infected with strains of H pylori that are resistant to antibiotics included in the eradication regimen than are achieved in people infected with sensitive strains of H pylori.
Antibiotics can cause adverse effects such as nausea and diarrhoea. Bismuth may turn the stools black.