Recommendation: weak. Quality of evidence: low or very low.
Recommendation: strong. Quality of evidence: moderate.
Recommendation: strong. Quality of evidence: moderate.
Recommendation: weak. Quality of evidence: low or very low.
If possible, culture and antimicrobial susceptibility testing should be performed following two treatment failures (Fig. 1) to tailor therapy and increase the likelihood of eradication success. Although tailoring first-line treatment on the basis of antimicrobial susceptibility testing has indicated improved eradication rates over standard therapies 81–84, tailoring second and subsequent therapies has been explored less. Data from the limited number of studies performed to date are encouraging 44,95. Culture and antimicrobial susceptibility testing should be performed at least 4 weeks following the completion of any treatment.
Recommendation: weak. Quality of evidence: low or very low.
Recommendation: strong. Quality of evidence: moderate.
There are limited data available on the use of sequential therapy as a rescue strategy for H. pylori infection 95,99. However, local data indicate suboptimal efficacy of sequential therapy as a first-line therapy 60. Moreover, studies have shown that the efficacy of sequential therapy is impacted by clarithromycin resistance and by dual metronidazole and clarithromycin resistance 80,100. Following the failure of clarithromycin-based triple therapy, clarithromycin resistance should be assumed. Similarly, data on the use of concomitant and hybrid therapy as a rescue strategy are limited and have not been investigated in Ireland to date. Thus, sequential, concomitant or hybrid therapies cannot be recommended for rescue therapy.
The resulting recommendations are intended to provide the most relevant current best-practice guidelines for the management of H. pylori infection in adult patients in Ireland, with a view to improving eradication rates and preventing the progression of H. pylori-associated disease. The success of these guidelines will require evaluation following implementation. On the basis of the relatively low-prevalence of H. pylori infection in Ireland, local validation of noninvasive H. pylori diagnostic tests should be performed. As antibiotic resistance is a constantly evolving process, an on-going effort to monitor antibiotic resistance rates, using both culture and molecular-based methods, should be made at a national level with centralized data collection established to accurately monitor the prevalence of resistance.
The authors would like to thank all of the Working Group members for their invaluable input into the project, especially Professor Peter Malfertheiner and Professor Francis Megraud, for travelling to Ireland to participate in the IHPWG Workshop. They also thank Associate Professor Tamasine Grimes, School of Pharmacy and Pharmaceutical Sciences, TCD, for advice on the national availability of medicinal products.
This work was supported by a Health Research Board Knowledge Exchange and Dissemination Scheme award (HEB-KEDS-2015-1616).
There are no conflicts of interest.
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