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PRESCRIPTION OF FIRST-LINE EMPIRICAL TREATMENTS FOR HELICOBACTER PYLORI INFECTION OUTSIDE EUROPE: RESULTS OF 10,000 CASES FROM THE WORLD-WIDE REGISTRY ON H. PYLORI MANAGEMENT (WORLDHPREG)

Olga P. Nyssen 1, Pablo Parra 1, Arnoldo Javier Riquelme Pérez 2, Diego Reyes-Placencia 3, Luiz Coelho 4, Ratha-Korn Vilaichone 5, Stella I. Smith 6, Lubna Kamani 7, Shivaram Prasad Singh 8, Maisam Akroush 9, Fahad Alsohaibani 10, Mohamed Alboraie 11, Sander Veldhuyzen Van Zanten 12, Peter Katelaris 13, Shailja C. Shah 14, Stephen Inns 15, José María Remes-Troche 16, Phubordee Bongkotvirawan 17, Oscar Laudanno 18, Sandro Rodrigues Chaves 19, william Otero 20, Rodrigo Castaño-Llano 21, Júlio César Soares Veloso 22, Leonardo Soares da Silva 23, James Marinho 24, Juan Ramirez 25, Hoiti Okamoto 26, Violet Kayamba 27, Christian von Muhlenbrock 28, Dacio Cabrera Hinojosa 29, guillermo otoya 30, Christian Campos Nuñez 31, Helenice Breyer 32, Gustavo Coutinho Couto 33, ERNESTO COMELLI 34, CHRISTIANE ALENCAR 35, Rosival Vicente De Paula 36, Laura Huidobro 37, Hugo Cedron 38, Virukalpatti G. Mohan Prasad 39, Luis Alberto Sobral Sousa 40, Cesar Vargas-Alayza 41, Ignacio Hanna-Jairala 42, Mariana Horn Andre 43, Manoj Kumar Sahu 44, Maria José Gilberto Massote 45, Ala Ali 46, Anna Cano-Catala 47, Leticia Moreira Ruiz 48, Javier P. Gisbert 1

Affiliations

1 Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Madrid, Spain

2 Department of Gastroenterology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Centro para la prevención y control del cáncer (CECAN), Santiago, Chile

3 Department of Gastroenterology, Pontificia Universidad Católica de Chile, Santiago, Chile

4 Instituto Alfa de Gastroenterologia, Hospital das Clínicas, Ebserh-UFMG, Belo Horizonte, Brazil

5 Center of Excellence in Digestive Diseases, Department of Medicine and Thailand Science Research and Innovation Fundamental Fund 2025, Gastroenterology Unit, Thammasat University, Pathum Thani, Thailand

6 Department of Molecular Biology and Biotechnology, Nigerian Institute of Medical Research, Yaba, Lagos, Nigeria

7 Department of Gastroenterology, Liaquat National Hospital, Karachi, Pakistan

8 Kalinga Gastroenterology Foundation, Cuttack, India

9 Faculty of Medicine, Jordan University, Amman, Jordan

10 Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

11 Department of internal medicine, Al-Azhar University, Cairo, Egypt

12 Division of Gastroenterology, University of Alberta Hospital, University of Alberta, Edmonton, Canada

13 Gastroenterology Department, Concord Hospital, University of Sydney, Sydney, Australia

14 Division of Gastroenterology, University of California San Diego (UCSD), Gastroenterology Section, VA San Diego Healthcare System, San Diego, California, United States

15 Department of Medicine, University of Otago, Department of Gastroenterology, Health New Zealand Te Whatu Ora Capital Coast and Hutt Valley, Wellington, New Zealand

16 Medical-Biological Research Institute, Universidad Veracruzana, Veracruz, Mexico

17 Center of Excellence in Digestive Diseases and Gastroenterology Unit, Thammasat University, Pathum Thani, Thailand

18 Instituto Doctor Alfredo Lanari, Buenos Aires, Argentina

19 Universidade Federal de Minas Gerais, Rede Mater Dei de Saúde, Belo Horizonte, Brazil

20 Universidad Nacional de Colombia, Bogota, Colombia

21 Gastrohepatología, Universidad de Antioquia, Cirugía, Universidad Pontificia Bolivariana, Medellin, Colombia

22 Hospital Santa Helena, Brasilia, Brazil

23 Hospital Adventista de Manaus, Manaus, Brazil

24 Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL), Maceió, Brazil

25 Department of Gastroenterology, Liga Contra el Cáncer, Hospital Arzobispo Loayza, Lima, Peru

26 Department of Gastroenterology, Endoscopy Center, Oxford Medical Center, São Bento Sul, Santa Catarina, Brazil

27 Department of Internal Medicine, Univeristy of Zambia School of Medicine, Lusaka, Zambia

28 Digestive Diseases Center, Internal Medicine departament, Universidad de los Andes, Hospital Clínico Universidad de Chile, Santiago, Chile

29 Hospital Nacional Dos de Mayo, Lima, Peru

30 Jefe del Servicio de Gastroenterología del Hospital Nacional "Guillermo Almenara Irigoyen", Lima, Peru

31 Department of Gastroenterology, Hospital Clínica Bíblica, San José, Costa Rica

32 Department of Gastroenterology in Porto Alegre Clinical Hospital, Rio Grande do Sul, Brazil

33 Centro de Consultas Especializadas de Contagem, Contagem, Brazil

34 Department of Surgery and Digestive System Diseases, São Camilo Hospital Center, Department of Surgery, Unimed General Hospital and Center for Endoscopy and Intestinal Motility (Castromed), Brazil

35 Clinicas Reunidas São Victor, Rio de Janeiro, Brazil

36 Hospital Santa Marcelina, São Paulo, Brazil

37 Faculty of Medicine, Universidad Católica del Maule (UCM), Talca, Chile

38 Clínica Anglo Americana, Lima, Peru

39 Indira Gandhi Institute of Medical Sciences (IGIMS), Bihar, India

40 Private Practice, Gastroenterology Specialist, LV Consultórios Médicos, Recife, Brazil

41 Universidad Peruana de Ciencias Aplicadas UPC, Lima, Peru

42 Service of Gastroenterology, Department of Internal Medicine, Hospital Miguel H. Alcívar, Guayaquil, Ecuador

43 Endocentro clinic, Florianópolis, Santa Catarina, Brazil

44 Apollo Hospitals, Odisha, India

45 Gastroenterologist, Private Clinic, Santos, São Paulo, Brazil

46 Gastroenterology Department, Abdali Hospital, Amman, Jordan

47 Gastrointestinal Oncology, Endoscopy and Surgery (GOES) research group, Althaia Xarxa Assistencial Universitària de Manresa, Institut de Recerca i Innovació en Ciències de la Vida i de la Salut de la Catalunya Central (IRIS-CC), Manresa, Spain

48 Department of Gastroenterology, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelon

Summary

AI Generated

A global registry study of 7,738 first-line H. pylori treatments across non-European countries reveals substantial regional variation in therapeutic approaches and underutilization of quadruple therapies in most regions.

Standard triple therapy with PPIs or P-CABs plus amoxicillin-clarithromycin was the most common regimen (41% overall), particularly dominant in Brazil (87%), India (45%), and Latin America (27%).
Quadruple non-bismuth concomitant therapy was second most common globally (9%) but showed high regional variation, with predominant use in Canada (77%) and Jordan (30%) but underutilization in most other regions.
A total of 90 different first-line regimens were prescribed across Latin America, Brazil, Africa, ASEAN, Australia, Canada, Egypt, India, Jordan, Pakistan, and Saudi Arabia, with most treatments lasting 14 days (86%).
Diagnosis relied mainly on histology (75%), with limited use of non-invasive methods such as 13C-urea breath test (5.8%) and stool antigen test (4.7%).
The findings highlight the need for region-specific treatment protocols to optimize H. pylori eradication outcomes globally.

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This summary was generated by an AI large language model based on the content transcript. It is for informational purposes only and should not be considered a substitute for clinical judgment. Always rely on your professional expertise and the full clinical context when making clinical decisions.

Abstract

Introduction

H. pylori infection remains a major global health issue, and although effective treatment exists, changing clinical practices and regional differences require ongoing review of treatment guidelines.

Aims & Methods

This study aimed to assess the various first-line empirical therapies used for H. pylori infection in regions outside Europe.
The WorldHpReg is a global, multicenter, prospective registry designed to assess how gastroenterologists manage H. pylori infection and its clinical outcomes. Data were collected at AEG-REDCap e-CRF from March 2022 to April 2025, with descriptive analyses and Chi-square tests used to evaluate associations.

Results

Overall, 9,973 cases, with 7,738 (78%) first-line empirical prescriptions were analysed across several non-European countries, including: Latin America (LATAM), Brazil, Africa, Association of South-East Asian Nations (ASEAN), Australia, Canada, Egypt, India, Jordan, Pakistan, and Saudi Arabia. The average patient was 50 years old, with 62% being women. Ethnicities included Caucasian (33%), Asian (15%), Black (6.1%), and others (40%). Most patients (85%) had never smoked, while 11% were current smokers. At baseline, 38% used concurrent medications, primarily proton pump inhibitors (PPIs) (27%). Common symptoms were dyspepsia (59%) and heartburn (23%). H. pylori diagnosis was mainly by histology (75%), with limited use of 13C-urea breath test (5.8%), stool antigen test (4.7%), and culture (2%). A total of 90 different first-line therapeutic regimens were prescribed, with triple therapy using either Potassium-Competitive Acid Blockers (P-CABs) or PPIs plus amoxicillin-clarithromycin being the most common (41%), especially in Brazil (87% of their prescriptions), India (45%) and LATAM (27%). Quadruple non-bismuth concomitant therapy with PPI-amoxicillin-clarithromycin-metronidazole was the second most common (9% overall), with higher usage in Canada (77% of their prescriptions), Jordan (30%) and LATAM (16%). Bismuth quadruple therapy using a single-capsule formulation of PPI-metronidazole-tetracycline was prescribed in LATAM (2.7% of their prescriptions) and Saudi Arabia (60%); while bismuth quadruple therapy with P-CABs or PPIs and other antibiotic combinations was less common (3% globally). Region-specific alternatives like triple therapy with PPI-amoxicillin-levofloxacin were prescribed in LATAM or Egypt, and PPI-clarithromycin-tinidazole was more frequent in Africa. Dual therapy with P-CAB or PPI plus amoxicillin was prescribed overall in 6.2% of cases, mainly in LATAM and Brazil (Table 1). Most treatments lasted 14 days (86%), with PPIs prescribed at either low-dose (20 mg omeprazole equivalent b.i.d.) in 42% of cases or high-dose (80 mg omeprazole equivalent b.i.d.) in 36% of cases. Vonoprazan, tegoprazan and fexuprazan were prescribed in 5%, 2% and 1.3% of cases.

Table 1. Most frequent first-line empirical treatments worldwide.

Country

LATAM

Brazil

Africa

ASEAN

Australia

Canada

Egypt

India

Jordan

Pakistan

Saudi Arabia

Treatment^(a)

N (%)

Triple-C+A

Concomitant-C+A+M

Dual-A

Quadruple-A+M+B

Quadruple-M+D+B

Triple-A+L

Quadruple-M+Tc+B

Quadruple-C+A+B

Quadruple-A+D+B

Single-capsule*

Triple-C+T

Overall

3,187
(41%)
692
(8.9%)
476
(6.2%)
273
(3.5%)
272
(3.5%)
221
(2.9%)
221
(2.9%)
204
(2.6%)
177
(2.3%)
153
(2%)
128
(1.7%)
7,736
(100%)

1,069
(27%)
635
(16%)
360
(9.2%)
273
(7%)
269
(6.9%)
133
(3.4%)
178
(4.5%)
197
(5%)
177
(4.5%)
104
(2.7%)
NA

3,916
(51%)

1,907
(87%)
1
(0%)
116
(5.3%)
NA

2
(0.1%)
16
(0.7%)
38
(1.7%)
6
(0.3%)
NA

NA

NA

2,183
(28%)

39
(17%)
NA

NA

NA

NA

NA

1
(0.4%)
NA

NA

NA

128
(57%)
224
(2.9%)

NA

1
(0.1%)
NA

NA

NA

NA

NA

NA

NA

NA

NA

791**
(10%)

19
(100%)
NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

19
(0.2%)

1
(3.2%)
24
(77%)
NA

NA

NA

NA

1
(3.2%)
NA

NA

NA

NA

31
(0.4%)

4
(5.1%)
NA

NA

NA

NA

46
(59%)
NA

NA

NA

NA

NA

78
(1%)

69
(45%)
NA

NA

NA

NA

NA

NA

1
(0.7%)
NA

NA

NA

152
(2%)

15
(14%)
31
(30%)
NA

NA

NA

1
(1%)
NA

NA

NA

1
(1%)
NA

104
(1.3%)

53
(34%)
NA

NA

NA

NA

12
(7.6%)
NA

NA

NA

NA

NA

158
(2%)

11
(14%)
NA

NA

NA

1
(1.3%)
13
(16.3%)
3
(3.8%)
NA

NA

48
(60%)
NA

80
(1%)

^(a)Treatments were categorised in 11 categories encompassing over 90% of first-line prescriptions world-wide; LATAM: Latin America; ASEAN: Association of South-East Asian Nations; A: amoxicillin; B: bismuth salts; C: clarithromycin; D: doxycycline; L: levofloxacin; M: metronidazole; T: tinidazole; Tc: tetracycline. *Three-in-one single-capsule containing metronidazole, tetracycline and bismuth; N: number of prescriptions; NA: non-available. **From other treatment combinations.

Conclusion

WorldHpReg reveals substantial heterogeneity in first-line empirical H. pylori treatments, with standard triple therapy predominating mainly in Africa, India, Pakistan, Latin America and Brazil; while quadruple therapies were underutilised in most regions except in Latin America, Jordan, Saudi Arabia and Canada. These findings highlight a critical need for region-specific protocols to optimise H. pylori eradication outcomes globally.

Disclosure

Javier P. Gisbert has served as speaker, consultant, and advisory member for or has received research funding from: Mayoly, Allergan/Abbvie, Diasorin, Richen, Juvisé and Biocodex.
Olga P. Nyssen received research funding from: Mayoly, Allergan/Abbvie, Richen, Juvisé and Biocodex.

Conference

UEG Week Berlin 2025

Topics

Stomach & H. Pylori

Submission format

Abstract

Session

H. pylori: Real world data (Posters)

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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