Systematic Evaluation of Helicobacter pylori Susceptibility to Antibiotics Before First-Line Treatment: A Cohort Study.

Background: European guidelines recommend that susceptibility tests be routinely performed, even before prescribing first-line treatment of Helicobacter pylori infection. However, empirical treatments are the rule in France, and susceptibility-guided treatments are the exception.

Objective: We aimed to report our experience of systematic antibiotic susceptibility testing before first-line treatment.

Methods: Prospective registration of all esofagogastroduodenoscopies performed in a community hospital from December 2023 to December 2024. Antral and fundic biopsies were performed, at the discretion of the endoscopist, for histological examination, polymerase chain reaction (PCR) and culture without any freezing.

Results: Overall, 3566 adults underwent esofagogastroduodenoscopy, 1785 (50.1%) were tested and H. pylori infection was diagnosed in 308 (17.3%) [95% confidence interval (CI): 15.5%-19.0%] individuals. The sensitivity of PCR for the diagnosis of H. pylori infection was 99.7%, significantly higher than those of histology (94.1%) and culture (95.2%) (p < 0.01). Clarithromycin resistance was observed in 22.6% [95% CI: 17.9%-27.3%] and levofloxacin resistance in 18.6% [95% CI: 14.1%-23.2%] of cases. Among 285 patients treated, susceptibility-guided triple therapy was prescribed in 84.9% of cases (73.3% amoxicillin-clarithromycin, 11.6% amoxicillin-levofloxacin) and quadruple bismuth therapy in 14.4% of cases. The eradication rates were 98.1% [95% CI: 96.0%-100%] for triple therapy amoxicillin-clarithromycin and 100% [95% CI: 100%-100%] for amoxicillin-levofloxacin, significantly higher than 81.3% [95% CI: 67.7%-94.8%] for quadruple bismuth therapy (p < 0.01 and p = 0.03, respectively). Overall, of 218 (70.8%) patients evaluated by the C13 urea breath test, H. pylori was eradicated in 209 (95.9%) [95% CI: 93.2%-98.5%] patients. The PCR-based diagnostic and therapeutic strategy was more cost-effective than the immunohistochemistry-based strategy.

Conclusion: A PCR-based susceptibility-guided strategy is easy to implement in routine clinical practice. In more than 7 in 10 patients, PCR enabled the offer of a susceptibility-guided triple therapy that was more effective and less costly than empirical quadruple bismuth therapy. Culture enabled one additional patient in 10 to be offered a susceptibility-guided triple therapy.