Introduction

Helicobacter (H.) pylori is the main cause of gastric cancer (GC). The prevalence of H. pylori is largely dynamic and heterogeneous worldwide. Despite decreasing rates, GC is still an important cause of morbidity and mortality and the total numbers of cases vary in different countries worldwide.

Aims & Methods

We aimed to predict the attributable fraction (AF) of GC for H. pylori and the number of new GC cases attributable to H. pylori in different geographic region and countries worldwide in 2040. We performed a systematic review and meta-analysis to estimate H. pylori prevalence in the general population restricted to the period 2010-2022. A random effect model was used to calculate pooled prevalence and 95% confidence interval (CI) of H. pylori infection by country and geographical region. The AF formula originally described by Levin (1) was adopted to calculate the proportion of GC attributable to H. pylori using region- and country-specific H. pylori prevalence and a relative risk (RR) of 5.9 between H. pylori and GC (2). The number of new GC cases attributable to H. pylori was calculated by multiplying the AF by the number of new GC cases estimated from GLOBOCAN Tomorrow for the year 2040 (3). The AF estimates were provided for 162 selected countries from 7 regions with available data.

Results

The overall H. pylori prevalence in the period 2010-2022 was 46%. The countries with the highest H. pylori prevalence were Guatemala (87%), Portugal (85%), Poland (84%), Egypt (81%), Mongolia (80%), Afghanistan (76%), Spain (74%), Latvia (73%) and Bulgaria (72%) The average AF of GC for H. pylori is 69.3%, ranging from 42.4 in Switzerland and Indonesia to 81% in Guatemala. The average AF is higher than 70% in East Mediterranean Region (72.1%), Africa (71.4%), and Europe (70.2%), while North America has the lowest AF (63.2%), still impacting on the majority of GC. Countries with the highest projected number of new GC cases attributable to H. pylori in 2040 are China (546.498), Japan (138.257) and India (100.662), followed by Russia (45.347), Korea (42.861) and Iran (37.045). In Europe, Germany and Italy have similar numbers (respectively, 16.388 and 16.996), while numbers are below 10.000 in the other countries. Projected number of new GC cases attributable to H. pylori in 2040 are higher than 10,000 also in Vietnam (25,259) and Bangladesh (13,724). Predicted numbers are <5000 in the African Region.

Conclusion

We provided data on predicted GC cases attributable to H. pylori infection in 2040 for 162 countries and 7 regions worldwide. These data are helpful for policy makers and cost-effectiveness analyses on GC prevention strategies focused on population-based H. pylori “test-and-treat”.

References

1. Levin ML: The occurrence of lung cancer in man. Acta Unio Int Contra Cancrum 1953, 9:531–541.
2. Helicobacter and Cancer Collaborative Group. Gastric cancer and Helicobacter pylori: a combined analysis of 12 case control studies nested within prospective cohorts. Gut 2001; 49: 347–53.
3. https://gco.iarc.fr/en Accessed on 15 March 2024

Disclosure

None to declare

Introduction

It remains uncertain if the addition of Saccharomyces boulardii (S. boulardii) to Vonoprazan-amoxicillin dual therapy as a first-line treatment can enhance the Helicobacter pylori (H. pylori) eradication rate and decrease the incidence of adverse events. Therefore, we conducted the randomized controlled trials (RCTs) to address this issue.

Aims & Methods

This is a single-center, prospective randomized controlled study. A total of 150 eligible patients, recruited from December 2023 to November 2024, were randomly assigned to the VA (vonoprazan 20 mg twice daily, amoxicillin 750 mg 3 times daily for 10 days) and VAS groups (vonoprazan 20 mg twice daily, amoxicillin 750 mg 3 times daily, and S. boulardii 250 mg twice daily for 10 days). The eradication rates, adverse events, safety, and compliance were compared between the two groups. Factors associated with eradication rate were explored.

Results

The eradication rates of VA and VAS were 89.3% and 93.3%, respectively, by intention-to-treat analysis (P = 0.384); 93.1%, and 94.6%, respectively, by per-protocol analysis (P=0.966). The incidence of adverse events significantly lower in the VAS group (5.4%) than in the VA group (22.2%; P=0.003). There was no significant difference in compliance between the VA (96%) and VAS groups (98.7%, P = 0.612). Body surface area (BSA) was found to be a influencing factor for eradication rate in both VA and VAS groups. Serum chemistry tests revealed no significant differences in liver and kidney function before and after treatment in both groups.

Conclusion

Although the addition of S. boulardii to VA dual therapy could not increase the eradication rate, it could decrease the incidence of adverse events. Low-BSA patients are more suitable candidates for this regimen.

Introduction

H. pylori infection represents a significant global health challenge. Despite international efforts to standardise eradication protocols, treatment success varies substantially across regions due to differences in antibiotic resistance patterns and healthcare practices and accessibility.

Aims & Methods

This study aimed to assess the effectiveness of empirical first-line therapies for H. pylori infection outside Europe.
The WorldHpReg, an international, multicenter, prospective registry, was created to evaluate the management and clinical outcomes of H. pylori infection by gastroenterologists world-wide. Data were collected via the AEG-REDCap e-CRF from March 2022 to April 2025. Modified intention-to-treat (mITT) and per-protocol (PP) analyses were performed to assess therapy effectiveness. A regimen was considered optimally effective if the mITT cure rate was ≥90%. The data were stratified by country and by specific first-line therapeutic regimen.

Results

A total of 9,973 cases were collected, with 7,738 (78%) first-line empirical prescriptions analysed across several non-European countries including: Latin America (LATAM), Brazil, Africa, Australia, Canada, Egypt, India, Jordan, Pakistan, and Saudi Arabia. Overall, 90 different first-line therapeutic regimens were prescribed, achieving an overall mITT and PP effectiveness of 84% and 85%, respectively. Optimal (≥90%) mITT cure rates were achieved, overall, in Australia (95%), India (99%), Jordan (96%) and Saudi Arabia (91%). Optimal treatment effectiveness was observed in LATAM with following therapies: non-bismuth quadruple therapy containing amoxicillin-clarithromycin-metronidazole (91%) or with various combinations of bismuth-containing quadruple therapies, such as amoxicillin-metronidazole (94%), metronidazole-doxycycline (90%), and amoxicillin-doxycycline (97%). Additionally, high effectiveness was achieved also in LATAM with the single-capsule formulation (94%) and with the combination of metronidazole-tetracycline in the classical format (91%), this latter also obtaining optimal results in Brazil (97%). Standard triple therapy with amoxicillin-clarithromycin achieved over 90% mITT cure rates in Africa (92%), Australia (95%), Egypt (100%), India (100%), and Jordan (100%), although the number of patients was still very low. The remaining regimens provided suboptimal results. Complete results by treatment scheme and country are detailed in Table 1.

Conclusion

In this large, real-world cohort from several non-European countries, first-line H. pylori empirical eradication therapies yielded unsatisfactory overall results. However, optimal (≥90%) eradication rates were consistently observed in Australia, India, Jordan, Egypt and Saudi Arabia. In LATAM and Brazil, the highest cure rates were predominantly obtained with bismuth and non-bismuth quadruple therapies. Triple therapy with amoxicillin-clarithromycin remained highly effective in selected regions. These findings reinforce the importance of tailoring first-line empirical therapy to regional performance in order to optimise H. pylori eradication success.

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.

Introduction

Minocycline is considered the most potent semi-synthetic tetracycline, demonstrates promising pharmacokinetic and antimicrobial properties against Helicobacter pylori (H. pylori). While previous studies suggested the efficacy of minocycline-containing bismuth quadruple therapy for H. pylori eradication, real-world evidence remains limited.

Aims & Methods

his study aimed to evaluate the clinical efficacy, safety, and cost-effectiveness of minocycline-containing bismuth quadruple therapy in routine clinical practice.This multicenter, real-world observational study was conducted at 25 hospitals in Fujian China between January and March 2025. Patients diagnosed with H. pylori infection received one of three 14-day bismuth-containing quadruple regimens with b.i.d. esomeprazole 20 mg and bismuth 220 mg, plus amoxicillin 1000 mg b.i.d. and clarithromycin 250 mg b.i.d. (PBAC), or minocycline 100 mg b.i.d. and clarithromycin 250 mg b.i.d. (PBMC), or minocycline 100 mg twice b.i.d. and levofloxacin 500mg q.d. (PBML). The primary outcome was the H. pylori eradication rate, secondary outcomes included the frequency of adverse events, patient compliance, and cost-effectiveness.

Results

A total of 347 patients were enrolled, with 110 patients completing treatment in each group. In the intention-to-treat (ITT) analysis, eradication rates were 77.4% (PBAC), 85.5% (PBMC), and 84.3% (PBML). In the per-protocol (PP) analysis, eradication rates were 80.9%, 90.9%, and 88.2%, respectively. Although the differences among the three regimens were not statistically significant, minocycline-based regimens achieved numerically higher eradication rates. Adverse event incidence was 32.73%, 20.91%, and 23.64% in the three groups, respectively. Compliance rates exceeded 94% across all groups. Cost-effectiveness analysis showed PBML had the lowest cost-effectiveness ratio (5.38 CNY per 1% eradication), followed by PBAC (5.41 CNY) and PBMC (6.06 CNY).

Conclusion

H. pylori eradication, with favorable patient compliance and pharmacoeconomic profiles. These regimens present a viable alternative to traditional amoxicillin-or tetracycline-based therapies. Further large-scale randomized controlled trials are warranted to confirm these findings.

Introduction

Global rise in primary Helicobacter pylori (H. pylori) antibiotic resistance has led to a decrease in the treatment efficacy. Understanding the rates of clarithromycin (ClaR), metronidazole (MetR) and levofloxacin (LevR) resistance in H. pylori management is essential for determining the optimal eradication therapy and achieving successful clinical outcomes.

Aims & Methods

To evaluate the prevalence and geographical distribution of H. pylori primary ClaR, MetR and LevR in Europe. Bibliographical searches were conducted in PubMed until March 2024, with no language restrictions. Studies focused on children only or non-European countries were excluded.

Results

A total of 218 studies published since 1990 were included, of which 188 provided information on ClaR, 138 on MetR, and 77 on LevR (Table 1). The average ClaR in Europe, considering all studies and years, was 17%, showing an increase from 7.3% in the 1990s to 26% in the period 2010–2019, with a slight decrease to 22% in the period 2020–2024. The highest values were reported in Switzerland (66%), Ireland (50%), and Israel (44%). Southern European countries presented higher resistance rates (over 15–20%) compared to those in the north (under 10–15%). MetR remained consistently high (with a European average of 34%), particularly in Poland (66%), Turkey (67%), and Switzerland (60%). As for LevR, it was low in the 1990s but experienced a progressive increase over time, reaching approximately 15% during 2010–2019, and fluctuating between 20% and 25% in recent years.

Conclusion

In Europe, since the 1990s, primary ClaR has fluctuated but always remaining above 15%; MetR has remained consistently high; and LevR has shown a progressive increase throughout the study periods. These data highlight the urgent need for region-specific antibiotic stewardship and updated treatment guidelines to ensure H. pylori eradication success.

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.

Introduction

Due to the increasing prevalence of antimicrobial resistance, the efficacy of standard triple therapy for Helicobacter pylori (H. pylori) infection has declined, with eradication rates now falling below 80% in most countries. Although bismuth quadruple therapy and concomitant therapy are advised in regions with high clarithromycin resistance, these treatments commonly cause frequent adverse events and require the use of two or three antibiotics.

Aims & Methods

Aim: To evaluates the effectiveness of 14-day mono-antibiotic therapies for the first-line treatment of H. pylori infection.
Methods: Randomized controlled trials published in English that reported the efficacies of 14-day high-dose amoxicillin/PPI dual, 14-day high-dose amoxicillin/vonoprazan dual, and 14-day tetracycline/vonoprazan dual therapies for the first-line treatment of H. pylori infection in adults were included in our literature search. Medical literature searches were conducted using PubMed, Embase, and Cochrane Library electronic databases from October 1, 2014, to October 1, 2024.

Results

The pooled eradication rates for 14-day high-dose amoxicillin/proton-pump inhibitor (PPI) dual therapies were 86.1% (3335/3875; 95% confidence interval [CI]: 85.1% - 87.2%) by intention-to-treat (ITT) analysis and 87.3% (3232/3702; 95% CI: 86.2% - 88.4%) by per-protocol (PP) analysis. For 14-day high-dose amoxicillin/vonoprazan dual therapies, the rates were 87.4% (1085/1241; 95% CI: 85.5% - 89.2%) by ITT and 93.0% (1044/1124; 95% CI: 91.5% - 94.5%) by PP. In the penicillin-allergic population, 14-day tetracycline/vonoprazan dual therapy showed eradication rates of 92.0% (138/150) by ITT and 95.1% (135/142) by PP.

Conclusion

14-day tetracycline/vonoprazan dual therapy presents an effective option for eradicating H. pylori in patients allergic to penicillin. For those without a penicillin allergy, first-line treatments can include 14-day mono-antibiotic regimens such as high-dose amoxicillin/PPI dual, high-dose amoxicillin/vonoprazan dual, and tetracycline/vonoprazan dual therapies.

Disclosure

All the authors disclose no conflict of interest.

Introduction

Gastric peroral endoscopic myotomy (G-POEM) has proven to be an effective technique for treating refractory gastroparesis^1,2. However, data on the long-term outcomes of the technique remain limited. We present findings from a multicenter study with over one year of follow-up.

Aims & Methods

In this retrospective study, patients undergoing G-POEM for refractory gastroparesis at two Italian centers from March 2019 to October 2024 were included. Primary endpoints were clinical success rates at 1 and 2 years. Secondary endpoints included factors associated with long-term clinical success (CS), changes in Gastric Emptying Study (GES) results, and Body Mass Index (BMI). CS was defined as a ≥1-point improvement in the Gastroparesis Cardinal Symptom Index (GCSI) and a 25% reduction in two symptom subscales.

Results

A total of 56 patients underwent G-POEM (median age 61 years [IQR 25: 45.8 - IQR 75: 71.5], 57.1% female, and 60.8% with idiopathic gastroparesis).
Technical success was achieved in 54 out of 56 cases (96.4%). Only two adverse events were recorded (3.5%, both grade 1 according to the AGREE classification). The median length of myotomy was 3.00 cm (IQR 25: 3.00 - IQR 75: 5.00). Single-layer myotomy was performed in 12 patients (21.4%), while 42 patients (78.6%) underwent full-thickness myotomy.
CS rates were 70.0% (35/50 patients) at 3 months, 66.7% (31/45 patients) at 6 months, 64.9% (24/37 patients) at 12 months, and 57.1% (16/28) at 24 months, with a significant change over time (𝑄=25.36, p<0.001). Among patients with CS at 12 months, 4 experienced symptoms relapse at 24 months, while 1 patient achieved success at 24 months despite not having CS at 12 months. There were no differences in success rates based on the etiology of gastroparesis (Table 1)
In multivariate regression logistic, age (OR = 1.27, p=0.02) and baseline GCSI (OR = 1.45, p=0.03) were significant predictors of CS at 1 year.
Among patients with CS at two years, there was no significant difference between pre-procedure and post-procedure BMI (median follow-up time 1091 days)(22.6 vs 22.0, p=0.40) or between pre- and post-procedure GES t ½ (median follow-up time 901 days)(174 vs 101 min, p=0.078).

Table 1: Clinical success subgroup analysis

Conclusion

The efficacy of G-POEM decreases over time, reaching approximately 60% at two years. Long-term clinical success does not correlate with changes in BMI or GES parameters. Further studies are needed to better understand factors influencing long-term outcomes of G-POEM and to optimize patient selection.

References

1. Mandarino FV, Vespa E, Barchi A, et al. Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review. Life (Basel). 2023;13(11):2143. Published 2023 Oct 31. doi:10.3390/life13112143
2. Mandarino FV, Testoni SGG, Barchi A, et al. Gastric emptying study before gastric peroral endoscopic myotomy (G-POEM): can intragastric meal distribution be a predictor of success?. Gut. 2023;72(5):1019-1020. doi:10.1136/gutjnl-2022-327701