Susceptibility testing for H pylori is widely available in the U.S. and should help optimize treatments to get success rates >95%. Testing is now available for the most common treatment antibiotics: amoxicillin, metronidazole, tetracycline, levofloxacin, clarithromycin, and rifabutin.
Handling/shipping specimens properly is important with susceptibility testing
The authors recommend a PPI which is minimally-affected by CYP2C19 metabolism, namely rabeprazole or esomeprazole.
Provide careful instructions to patient/family regarding treatment
Susceptibility Testing Labs (see Table 1):
Quest: Our Quest representative indicated code: 36994 (H. pylori culture with reflex to susceptibility). Preferred Specimen: 3 mm Gastric/Antral or Duodenal biopsy collected in Brucella broth or Trypticase Soy Broth (TSB) with 10-20% glycerol
Culture (Catalog HELIS) or Stool PCR testing (Catalog HPFRP) can be done by Mayo Clinic
Reflex stool testing as well as PCR gastric testing from formalin is available through by American Molecular laboratories
A treatment algorithm is listed:
In the absence of highly effective empiric treatment or after treatment failure, the authors recommend susceptibility testing.
If clarithromycin susceptible, then a 14-day clarithromycin triple therapy course is recommended
If clarithromycin resistant but metronidazole susceptible, then 14-day metronidazole triple therapy
If resistant to both clarithromycin and metronidazole, then either a 14-day bismuth quadruple therapy, or a rifabutin triple therapy are preferred. However, if H pylori organisms are levofloxacin susceptible, then 14-day levofloxacin triple therapy may be a good option.
The authors recommend quinolone therapy only in the setting of susceptibility testing due to the FDA warnings about long-term adverse effects.
My take: Perhaps H pylori susceptibility testing availability needs to be a quality metric for hospitals and endoscopy centers.
One option may be a stool PCR test to determine susceptibility. As with all situations, there needs to be some shared decision-making and empiric treatment is an option as well as obtaining susceptibility via endoscopy
So if a patient is referred from PCP with positive stool test or breath test, do we scope for biopsy specimen to help determine proper treatment?
By Ben Enav on May 10, 2022 at 8:34 am
One option may be a stool PCR test to determine susceptibility. As with all situations, there needs to be some shared decision-making and empiric treatment is an option as well as obtaining susceptibility via endoscopy
By gutsandgrowth on May 10, 2022 at 10:08 am