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December 16-18, 2021, hosted by the Chinese Medical Association and the Chinese Medical Association Gastroenterology Branch, undertaken by the Jiangxi Provincial Medical Association, the Jiangxi Provincial Medical Association Gastroenterology Branch, and co-organized by the First Affiliated Hospital of Nanchang University The 21st National Conference on Digestive System Diseases (CGC 2021) was held in Nanchang
.
At the conference, Professor Song Zhiqiang from Peking University Third Hospital gave a wonderful academic report on the theme of "Eradication Treatment of Refractory Helicobacter Pylori Infection".
Yimaitong summarized the main content and presents it as follows for you
.
Prof.
Song Zhiqiang, Chief Physician, Associate Professor, Tutor of Gastroenterology, Peking University Third Hospital, Member and Secretary of the Gastroenterology Branch of Beijing Medical Association, Member of the Helicobacter Pylori and Early Cancer Group of the Chinese Medical Association Gastroenterology Branch of the Chinese Medical Association Member of the Youth Committee Member and Secretary of the Helicobacter Pylori Group of the Chinese Medical Association Digestive Diseases Branch Member of the Small Intestine Group of the Chinese Medical Association Digestive Endoscopy Branch, etc.
1.
The definition of refractory Helicobacter pylori (Hp) infection will usually be continuously regulated by different drugs The combination regimen was defined as refractory Hp infection without successful eradication treatment for ≥2 times
.
According to statistics, the proportion of patients with refractory Hp infection in China is at least 5-10%
.
The following points should be paid attention to when diagnosing refractory Hp infection: Difference from recurrence of Hp infection: reinfection and re-ignition; the same or similar eradication plan should be combined into one treatment; the course of medication or the number of treatments is too short or too few, It should not be counted as the number of eradications; inaccurate diagnosis and evaluation after eradication treatment is common
.
2.
Analysis of the causes of refractory Hp infection There are many reasons for refractory Hp infection, including Hp strain factors, host factors, drug factors and doctor factors
.
Hp strain factors: Hp strain drug resistance is the main cause of refractory Hp infection, including primary drug resistance and secondary drug resistance after repeated use of antibiotics
.
Host factors: For example, CYP2C19 gene polymorphism can affect the efficacy of eradication therapy; patients with allergies or intolerance to penicillin and other drugs lead to restriction of amoxicillin use, which makes treatment difficult; poor patient compliance may also affect the therapeutic effect
.
Drug factors: Clarithromycin, levofloxacin and metronidazole are clinically easy to obtain, but they are generally drug-resistant.
Eradication regimens containing these drugs are susceptible to drug resistance; tetracycline and furazolidone are sensitive and effective, but difficult to obtain clinically.
Widely used
.
Doctor factor: There are irregular problems in the diagnosis and treatment of Hp infection in many areas
.
3.
Does refractory Hp infection need eradication treatment? The need for eradication treatment depends on the principle of net benefit
.
Professor Song Zhiqiang listed several reasons for not recommending eradication and recommending eradication, and finally concluded that, weighing the pros and cons, if there are standardized and reasonable eradication conditions, the benefits of active eradication treatment will be greater
.
Reasons not recommended for eradication: eradication of Hp only benefits a small number of patients (1-3% of patients with Hp infection have gastric cancer, 10-15% have peptic ulcers, and 30% have dyspepsia.
It may not be possible for other patients without Hp eradication.
There will be too big a problem)
.
In addition, the treatment of refractory Hp infection has been difficult, the efficacy of re-administration of drugs is not good, the detection of drug sensitivity is difficult, and the risk of adverse drug reactions is higher
.
Moreover, some studies have shown that Hp has a certain protective effect, and population eradication may have potential long-term adverse effects
.
Reasons for the proposed eradication: First of all, through standardized and reasonable drug selection, the eradication rate of Hp is still very high
.
Secondly, the outcome of different infected individuals is difficult to predict and can only benefit from overall disease protection
.
In addition, Hp infection has the risk of cross-transmission, and it is difficult to eradicate the infected
.
Moreover, patients with refractory Hp infection have a huge psychological burden and very inconvenient life, so it is recommended to eradicate it
.
Fourth, the eradication strategies and programs of refractory Hp infection first need to conduct standardized and accurate diagnostic evaluation, confirm the diagnosis, and understand the details of the medication history
.
Secondly, it is not recommended to rush to sterilization.
Hp damages the gastric mucosa slowly, and will not have a significant impact in the short term, and will not cause significant transmission.
It can be treated when the bacteria are in an active multiplication state
.
Patients should not try drugs at will, and it is recommended to be referred to an experienced doctor/center or institution with drug resistance testing conditions for treatment
.
Combining research progress and the actual situation in China, the recommended eradication program is as follows: eradication treatment: 14 days; eradication time: 3-6 months from the last eradication; treatment framework: proton pump inhibitor (PPI) + bismuth + two antibiotics ; Fully communicate medication details, precautions, possible adverse reactions and countermeasures with patients, emphasize the importance of compliance, and follow up closely
.
Professor Song Zhiqiang shared 6 empirical options for antibiotics based on the retrieved research literature and clinical medication experience
.
Figure 1 Professor Song Zhiqiang shared the empirical antibiotic selection plan.
For refractory Hp infection, other possible treatment drugs/plans include rifabutin, dual regimen, minocycline, and enhanced gastric acid suppression
.
Rifabutin is an anti-tuberculosis drug.
In recent years, it has been mainly combined with amoxicillin for third-line or fourth-line treatment in foreign countries.
There is no relevant research report in China.
Because China is a big country with tuberculosis, it is possible to eradicate Hp by using rifabutin widely in the country.
Will be subject to certain restrictions
.
The dual regimen for the treatment of refractory Hp infection needs further study
.
Minocycline is a semi-synthetic tetracycline.
When classic tetracycline is difficult to obtain, minocycline can be considered as an alternative
.
There are three main ways to strengthen gastric acid suppression: ①Increase the dose of PPI; ②CYP2C19 gene polymorphism detection to guide medication; ③Potassium ion competitive acid blocker (P-CAB) may improve the efficacy of Hp eradication
.
5.
Eradication treatment for penicillin allergy patients Foreign data show that penicillin allergy patients account for about 5-10%, and the eradication treatment of Hp infection in this part of patients is facing difficulties
.
However, in China, the proportion of patients who cannot use amoxicillin clinically for various reasons is much higher than that of true allergic patients.
The reasons include past penicillin allergy, positive penicillin skin test, no skin test conditions, and other adverse reactions.
However, only a small number of patients have immune-mediated allergic reactions
.
Therefore, Professor Song Zhiqiang suggested that clinicians should carefully inquire about the relevant medical history, exclude confounding factors, and retain the use of amoxicillin as much as possible under the premise of meeting the requirements of clinical norms
.
Professor Song Zhiqiang searched the main research on the first-line eradication treatment of Hp infection in penicillin allergic patients and found that the following 3 medication regimens are effective: PPI + clarithromycin + metronidazole (full dose) + bismuth for 14 days; PPI + cefuroxime + levofloxacin + Bismuth agent for 14 days; PPI + tetracycline + metronidazole (full dose) + bismuth agent
.
According to the current literature, Professor Song Zhiqiang recommended 3 antibiotic combinations that may be used for eradication treatment of patients with penicillin allergy
.
Table 1 Recommended antibiotic combinations
.
At the conference, Professor Song Zhiqiang from Peking University Third Hospital gave a wonderful academic report on the theme of "Eradication Treatment of Refractory Helicobacter Pylori Infection".
Yimaitong summarized the main content and presents it as follows for you
.
Prof.
Song Zhiqiang, Chief Physician, Associate Professor, Tutor of Gastroenterology, Peking University Third Hospital, Member and Secretary of the Gastroenterology Branch of Beijing Medical Association, Member of the Helicobacter Pylori and Early Cancer Group of the Chinese Medical Association Gastroenterology Branch of the Chinese Medical Association Member of the Youth Committee Member and Secretary of the Helicobacter Pylori Group of the Chinese Medical Association Digestive Diseases Branch Member of the Small Intestine Group of the Chinese Medical Association Digestive Endoscopy Branch, etc.
1.
The definition of refractory Helicobacter pylori (Hp) infection will usually be continuously regulated by different drugs The combination regimen was defined as refractory Hp infection without successful eradication treatment for ≥2 times
.
According to statistics, the proportion of patients with refractory Hp infection in China is at least 5-10%
.
The following points should be paid attention to when diagnosing refractory Hp infection: Difference from recurrence of Hp infection: reinfection and re-ignition; the same or similar eradication plan should be combined into one treatment; the course of medication or the number of treatments is too short or too few, It should not be counted as the number of eradications; inaccurate diagnosis and evaluation after eradication treatment is common
.
2.
Analysis of the causes of refractory Hp infection There are many reasons for refractory Hp infection, including Hp strain factors, host factors, drug factors and doctor factors
.
Hp strain factors: Hp strain drug resistance is the main cause of refractory Hp infection, including primary drug resistance and secondary drug resistance after repeated use of antibiotics
.
Host factors: For example, CYP2C19 gene polymorphism can affect the efficacy of eradication therapy; patients with allergies or intolerance to penicillin and other drugs lead to restriction of amoxicillin use, which makes treatment difficult; poor patient compliance may also affect the therapeutic effect
.
Drug factors: Clarithromycin, levofloxacin and metronidazole are clinically easy to obtain, but they are generally drug-resistant.
Eradication regimens containing these drugs are susceptible to drug resistance; tetracycline and furazolidone are sensitive and effective, but difficult to obtain clinically.
Widely used
.
Doctor factor: There are irregular problems in the diagnosis and treatment of Hp infection in many areas
.
3.
Does refractory Hp infection need eradication treatment? The need for eradication treatment depends on the principle of net benefit
.
Professor Song Zhiqiang listed several reasons for not recommending eradication and recommending eradication, and finally concluded that, weighing the pros and cons, if there are standardized and reasonable eradication conditions, the benefits of active eradication treatment will be greater
.
Reasons not recommended for eradication: eradication of Hp only benefits a small number of patients (1-3% of patients with Hp infection have gastric cancer, 10-15% have peptic ulcers, and 30% have dyspepsia.
It may not be possible for other patients without Hp eradication.
There will be too big a problem)
.
In addition, the treatment of refractory Hp infection has been difficult, the efficacy of re-administration of drugs is not good, the detection of drug sensitivity is difficult, and the risk of adverse drug reactions is higher
.
Moreover, some studies have shown that Hp has a certain protective effect, and population eradication may have potential long-term adverse effects
.
Reasons for the proposed eradication: First of all, through standardized and reasonable drug selection, the eradication rate of Hp is still very high
.
Secondly, the outcome of different infected individuals is difficult to predict and can only benefit from overall disease protection
.
In addition, Hp infection has the risk of cross-transmission, and it is difficult to eradicate the infected
.
Moreover, patients with refractory Hp infection have a huge psychological burden and very inconvenient life, so it is recommended to eradicate it
.
Fourth, the eradication strategies and programs of refractory Hp infection first need to conduct standardized and accurate diagnostic evaluation, confirm the diagnosis, and understand the details of the medication history
.
Secondly, it is not recommended to rush to sterilization.
Hp damages the gastric mucosa slowly, and will not have a significant impact in the short term, and will not cause significant transmission.
It can be treated when the bacteria are in an active multiplication state
.
Patients should not try drugs at will, and it is recommended to be referred to an experienced doctor/center or institution with drug resistance testing conditions for treatment
.
Combining research progress and the actual situation in China, the recommended eradication program is as follows: eradication treatment: 14 days; eradication time: 3-6 months from the last eradication; treatment framework: proton pump inhibitor (PPI) + bismuth + two antibiotics ; Fully communicate medication details, precautions, possible adverse reactions and countermeasures with patients, emphasize the importance of compliance, and follow up closely
.
Professor Song Zhiqiang shared 6 empirical options for antibiotics based on the retrieved research literature and clinical medication experience
.
Figure 1 Professor Song Zhiqiang shared the empirical antibiotic selection plan.
For refractory Hp infection, other possible treatment drugs/plans include rifabutin, dual regimen, minocycline, and enhanced gastric acid suppression
.
Rifabutin is an anti-tuberculosis drug.
In recent years, it has been mainly combined with amoxicillin for third-line or fourth-line treatment in foreign countries.
There is no relevant research report in China.
Because China is a big country with tuberculosis, it is possible to eradicate Hp by using rifabutin widely in the country.
Will be subject to certain restrictions
.
The dual regimen for the treatment of refractory Hp infection needs further study
.
Minocycline is a semi-synthetic tetracycline.
When classic tetracycline is difficult to obtain, minocycline can be considered as an alternative
.
There are three main ways to strengthen gastric acid suppression: ①Increase the dose of PPI; ②CYP2C19 gene polymorphism detection to guide medication; ③Potassium ion competitive acid blocker (P-CAB) may improve the efficacy of Hp eradication
.
5.
Eradication treatment for penicillin allergy patients Foreign data show that penicillin allergy patients account for about 5-10%, and the eradication treatment of Hp infection in this part of patients is facing difficulties
.
However, in China, the proportion of patients who cannot use amoxicillin clinically for various reasons is much higher than that of true allergic patients.
The reasons include past penicillin allergy, positive penicillin skin test, no skin test conditions, and other adverse reactions.
However, only a small number of patients have immune-mediated allergic reactions
.
Therefore, Professor Song Zhiqiang suggested that clinicians should carefully inquire about the relevant medical history, exclude confounding factors, and retain the use of amoxicillin as much as possible under the premise of meeting the requirements of clinical norms
.
Professor Song Zhiqiang searched the main research on the first-line eradication treatment of Hp infection in penicillin allergic patients and found that the following 3 medication regimens are effective: PPI + clarithromycin + metronidazole (full dose) + bismuth for 14 days; PPI + cefuroxime + levofloxacin + Bismuth agent for 14 days; PPI + tetracycline + metronidazole (full dose) + bismuth agent
.
According to the current literature, Professor Song Zhiqiang recommended 3 antibiotic combinations that may be used for eradication treatment of patients with penicillin allergy
.
Table 1 Recommended antibiotic combinations
