Introduction The Public Health England (PHE) advises HP testing and treatment if positive, in patients without alarm symptoms who have uncomplicated dyspepsia unresponsive to lifestyle change and antacids. However, the suggested antibiotic therapy is incongruent with latest Maastricht V/Florence guidelines which suggest bismuth containing quadruple therapy first line in regions with high metronidazole and clarithromycin resistance and second line routinely.¹ In London, a study showed overall resistance to metronidazole at 59% and clarithromycin at 11% with non-UK birth being main risk factor.² Our trust serves a local population where 31% consist of black and ethnic minorities. We aimed to look at our local HP resistance data and compare the antibiotics regimes used in different trusts within London.

Methods A list of all gastroscopies with CLO testing over a year between October 2017–18 was generated.

A list of all HP isolates sent to the microbiology lab over a 2-year period from January 2016 to December 2018 was generated.

We performed a search on the ‘Microguide’ app for HP antibiotic regimes for trusts within London.

Results Between October 2017 and September 2018, the endoscopy unit performed 1375 CLO tests out of 5000 gastroscopies. A review of 100 patients who had CLO testing showed that they were all appropriate.

Between 2016 and 2018, 36 isolates of HP were cultured. 35 were resistant to metronidazole, 26 to clarithromycin, 10 to levofloxacin, 1 to tetracycline and none to amoxicillin.

We found antibiotics guidelines for 6 London trusts on ‘Microguide’. None used antibiotic duration of 10-14 days and only 1 out of 6 recommended quadruple bismuth therapy as second line treatment.

Conclusion Patients in whom we send HP resistance testing have high resistance rates to conventional first line antibiotics. Given that these patients are likely to have previously failed at least one treatment regime; the results are inevitable skewed towards resistant isolates. While NICE and PHE guidelines are appropriate for some populations, areas of London which are at risk of higher resistance rates should use Maastricht guidelines. Therefore, we recommend a 10-day course of bismuth-containing quadruple therapy as second line.

References

1. Malfertheiner P, Megraud F, O’Morain CA on behalf of the European Helicobacter and Microbiota Study Group and Consensus, et al. Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report. Gut 2017;66:6–30.

2. Elviss N, Owen R, Breathnach A, Palmer C, Shetty N. Helicobacter pylori antibiotic-resistance patterns and risk factors in adult dyspeptic patients from ethnically diverse populations in central and south London during 2000. Journal of Medical Microbiology 54:567–574.