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Update on H Pylori

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This is a short newsletter from the Health Protection Agency Helicobacter Working Group. The aim is to update you on recent developments in this area.

| |
|Helicobacter stool antigen tests |
| |
|Monoclonal tests produce fewer equivocal results, as a lower number of results appear in the grey zone. |
| |
|Launch Diagnostics have replaced their less sensitive polyclonal antibody-based Meridian HpSA test with a monoclonal test Meridian HpSA |
|PLUS. |
| |
|It is anticipated that the HpSA PLUS will have similar sensitivity and specificity to the Oxoid (previously DakoCytomation) HpStAR |
|monoclonal kit. There has been one direct comparison in 248 patients.1 |
| |
|Kit |
|Sensitivity % |
|Specificity % |
| |
|Meridian Polyclonal HpSA |
|92 |
|94 |
| |
|Meridian HpSA PLUS |
|97 |
|96 |
| |
|Oxoid HpStAR |
|96 |
|95 |
| |
| |
|1Zanetti MV, Mucignat G. Comparison of a new test with monoclonal antibodies versus other analogous tests for detection of H. pylori in |
|faecal specimens. Poster at AMCLI Sept 2006 published on Microbiologia Medica Vol. 21 N3 Year 2006. |
| |
|A business case looking at cost comparisons of stool antigen versus urea breath test versus serology is available at |
|http://www.hpa.org.uk/infections/topics_az/primary_care_guidance/menu.htm |

| |
|Quality Assurance - Helicobacter stool antigen tests |
|As you know, CPA accreditation requires that laboratories undertake QA for all tests they use. HP QA for stool antigen tests is now |
|available via LabQuality in Finland. LabQuality will be despatch QA simulated patient specimens in May and November. Enquiries should |
|be directed to Yvonne Bjorkman, who is the microbiology EQA scheme coordinator, at yvonne.bjorkman@labquality.fi or just |
|info@labquality.fi |

| |
|Guidance |
|When giving advice to GPs about Helicobacter pylori you may wish to refer them to the Health Protection Agency Helicobacter diagnostic |
|guidance and management of infection (antibiotic) guidance, both of which can be found at: |
|http://www.hpa.org.uk/infections/topics_az/primary_care_guidance/menu.htm |
|Recent data from Hong Kong indicates that prophylactic eradication of H. pylori infection reduces the risk of ulcers in patients on |
|NSAIDs. H. pylori test and treat and prophylactic eradication may be appropriate in patients commencing long-term NSAIDs, who are |
|recognised to be at increased risk of NSAID gastric complications. |

| |
|Suggested rescue treatments for Helicobacter pylori |
|Principles of treatment: |
|Compliance is the greatest determinant of success. |
|Use a PPI at gastroeosophageal reflux dose. |
|If possible, do not use a macrolides, metronidazole or quinolone if previously used for H. pylori or another infection. |
|Resistance is very rare for amoxicillin and tetracycline. |
|First line use 7 days; after that 14 days treatment. |
|Reinfection is very low in developed countries. |
|In Caucasians, for rescue treatment you may wish to use Rabeprazole as the PPI, as there is evidence it may attain higher concentrations |
|in individuals who metabolise PPIs rapidly. |

| |
|Suggested Treatment Protocol |
| |
|1st Line 7d bd PPI + Amox 1g + Clari 500mg |
| |
| |
|2nd Line 14d bd PPI + Amox 1g + Metronidazole 400mg |
| |
| |
|3rd Line 14d bd PPI + Bismuth |
|+ Tetracycline 500mg qds |
|+ Metronidazole 400mg tds |
| |
| |
|4th Line 14d bd Bismuth + PPI + Amoxicillin 1g |
|+ Levofloxacin 250mg (metanalysis 14 trials 80%) |
|or Rifabutin 300mg od (5 trials 72-78%) |
|or Furazolidone 200mg bd (9 trials, not UK 52-90%) |
| |
|In patients allergic to penicillin |
| |
|1st Line 7d bd PPI + Metronidazole 400mg + Clari 500mg |
| |
| |
|2nd Line 14d bd PPI + Bismuth |
|+ Tetracycline 500mg |
|+ Metronidazole 400mg |
| |
| |
|Culture-directed treatment |

-----------------------

The HPA Helicobacter Working Group:
Chair, Dr Cliodna McNulty, Secretary, Dr Marjorie Walker, Dr Robert Owen, Dr Louise Teare, Prof David Forman, Dr David Tompkins, Prof Kenneth McColl, Dr Anan Raghunath, Dr Peter Hawtin
Email: cliodna.mcnulty@hpa.org.uk
November 2007

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