Related to yesterday’s blog, here is an SNL commercial for the “Koohl” toilet (also with Benedict Cumberbatch) in 2016: SNL Koohl Toilet
DY Graham, SF Moss. Am J Gastroenterol 2022. 117: 524-528. Antimicrobial Susceptibility Testing for Helicobacter pylori Is Now Widely Available: When, How, Why
- 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
- LabCorp: Helicobacter pylori Culture Test Code Test Code 180885
- ARUP: Helicobacter pylori Culture Test Code 2006686
- 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.
Related blog posts:
- Next-Generation Treatment for H Pylori
- Why Is There Low Adherence to H pylori Guidelines
- PEnQuIN and Improving the Quality of Pediatric Endoscopy
- Quadruple Therapy for Helicobacter Pylori Favored in Toronto Guidelines -Adult Guidelines
- ACG Guideline for Helicobacter Pylori | gutsandgrowth -Adult Guidelines
- AGA: Best Practice Advice for Refractory H pylori
- Lots of Room to Improve with H pylori Treatment | gutsandgrowth
- Rifabutin-based Triple Therapy for H pylori | gutsandgrowth
- It is Getting Harder to Treat H pylori -Here’s Why
- Updated Pediatric H pylori Guidelines
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?
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