{"product_id":"h-pylori-treatment-success-rates-across-u-s-military-health-system-patients-2016-2018","title":"H. pylori Treatment Success Rates Across U.S. Military Health System Patients (2016–2018)","description":"\u003cp\u003eThis study reviewed the medical records of 1,966 U.S. Department of Defense patients treated for Helicobacter pylori (H. pylori) infection between October 2015 and September 2018. The best-performing treatment was tetracycline-based bismuth quadruple therapy, which cleared the infection in 85% of patients overall. Clarithromycin triple therapy was the most commonly prescribed regimen (63.9% of all regimens analyzed), but no regimen achieved an eradication rate above 90%. Active duty service members had lower clearance rates than non-active duty patients (70.6% vs. 75.5%, P=0.0449).\u003c\/p\u003e\n\n\u003ch1\u003eH. pylori Treatment Success Rates Across U.S. Military Health System Patients (2016–2018)\u003c\/h1\u003e\n\n\u003ch2\u003eTable of Contents\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\u003ca href=\"#ddn-key-points\"\u003eKey Points\u003c\/a\u003e\u003c\/li\u003e\n\n  \u003cli\u003e\u003ca href=\"#background\"\u003eBackground: Why This Research Matters\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#what-is-hpylori\"\u003eWhat Is H. pylori?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#study-methods\"\u003eHow the Study Was Conducted\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#patient-population\"\u003eWho Was Studied\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#key-findings\"\u003eKey Findings: Treatment Success Rates\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#regimen-comparisons\"\u003eComparing Treatment Regimens Head-to-Head\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#geographic\"\u003eGeographic Differences in Treatment Success\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#active-vs-nonactive\"\u003eActive Duty vs. Non-Active Duty Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#clinical-implications\"\u003eWhat These Findings Mean for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#limitations\"\u003eLimitations: What the Study Could Not Prove\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#recommendations\"\u003eRecommendations and Next Steps\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#ddn-faq\"\u003eFrequently Asked Questions\u003c\/a\u003e\u003c\/li\u003e\n\u003cli\u003e\u003ca href=\"#source\"\u003eSource Information\u003c\/a\u003e\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003c!-- ddn:keypoints:start --\u003e\n\u003ch2 id=\"ddn-key-points\"\u003eKey Points\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003eIn 1,966 Department of Defense patients treated from 2015 to 2018, tetracycline-based bismuth quadruple therapy cleared H. pylori in 85% overall.\u003c\/li\u003e\n\u003cli\u003eClarithromycin triple therapy was prescribed most often (63.9% of regimens), but no regimen cleared more than 90% of infections.\u003c\/li\u003e\n\u003cli\u003eActive duty service members cleared the infection less often than non-active duty patients (70.6% vs. 75.5%), a statistically significant difference.\u003c\/li\u003e\n\u003cli\u003eAll levofloxacin regimens had lower clearance rates than quadruple therapy and triple therapy across the whole population studied.\u003c\/li\u003e\n\u003cli\u003eBecause clearance was below 90% for every regimen, testing after treatment to confirm eradication is important in all settings.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c!-- ddn:keypoints:end --\u003e\n\n\n\u003ch2 id=\"background\"\u003eBackground: Why This Research Matters\u003c\/h2\u003e\n\n\u003cp\u003e\u003cem\u003eHelicobacter pylori\u003c\/em\u003e (H. pylori) is one of the most common bacterial infections worldwide. In the United States, a study of veterans at the Houston Veterans Affairs Hospital found that 28.9% tested positive for H. pylori antibodies. A larger study of U.S. adults found a seroprevalence (the percentage of people whose blood shows evidence of past or current infection) of 32.5%.\u003c\/p\u003e\n\n\u003cp\u003eH. pylori contributes to several serious diseases. These include peptic ulcer disease (sores in the lining of the stomach or upper intestine). They also include gastric cancer (stomach cancer). Another condition is marginal zone B cell lymphoma of Mucosa-associated lymphoid tissue (MALT) type (a type of cancer affecting immune cells in the stomach lining). The last is functional dyspepsia (persistent indigestion without a clear cause).\u003c\/p\u003e\n\n\u003cp\u003eEradicating H. pylori (clearing the infection completely) leads to improved outcomes for patients. A systematic review of 21 clinical trials involving 4,331 patients found that the Number Needed to Treat for dyspepsia was 14. This means that for every 14 patients treated for H. pylori, one additional patient experienced relief from dyspepsia symptoms.\u003c\/p\u003e\n\n\u003cp\u003eH. pylori eradication also reduces the risk of gastric cancer. Patients with MALT lymphoma have shown cure or improvement of their disease after H. pylori eradication.\u003c\/p\u003e\n\n\u003cp\u003eMultiple antibiotic regimens are effective against H. pylori. However, there are limited data in the United States comparing these regimens or examining how well they work in different geographic regions over the past 20 years. Researchers have repeatedly called for more research into treatment efficacy and antimicrobial resistance.\u003c\/p\u003e\n\n\u003cp\u003eThe most recent U.S. data before this study came from a retrospective study at two academic centers in Rhode Island from 2015 to 2018. That study showed the superiority of tetracycline quadruple therapy over other combinations and the superiority of a 14-day course over a 10-day course. However, like many recent studies on H. pylori, those data came from single regions or small hospital systems.\u003c\/p\u003e\n\n\u003cp\u003eMore data are needed to assess how well H. pylori treatment regimens work based on geography and population. This information would help physicians choose the best treatment for their patients, especially because resistance patterns for H. pylori vary by region.\u003c\/p\u003e\n\n\u003cp\u003eThe researchers aimed to measure the number of treatment successes and failures of various H. pylori treatment regimens among TRICARE beneficiaries. TRICARE beneficiaries include Department of Defense active duty service members, their dependents, and retirees. The military health system is a relatively closed system with rare opportunities for local network care. It shares an electronic health record across international locations, making it an ideal system to examine trends and successes in H. pylori treatment.\u003c\/p\u003e\n\n\u003cp\u003eThe military population is diverse racially and socioeconomically. Patients are treated in both community and academic hospital settings. Access-to-care differences are smaller, and there are fewer insurance obstacles when choosing antibiotic regimens.\u003c\/p\u003e\n\n\u003ch2 id=\"what-is-hpylori\"\u003eWhat Is H. pylori?\u003c\/h2\u003e\n\n\u003cp\u003eH. pylori is a type of bacteria that infects the stomach. It is very common, affecting roughly one-third of adults in the United States based on antibody testing. The infection is usually acquired in childhood.\u003c\/p\u003e\n\n\u003cp\u003eMany people with H. pylori never develop symptoms. However, the infection can cause chronic inflammation of the stomach lining. Over time, this inflammation can lead to:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003ePeptic ulcers (open sores in the stomach or upper intestine)\u003c\/li\u003e\n  \u003cli\u003eStomach cancer\u003c\/li\u003e\n  \u003cli\u003eMALT lymphoma (a cancer of immune cells in the stomach)\u003c\/li\u003e\n  \u003cli\u003eFunctional dyspepsia (persistent indigestion)\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eBecause H. pylori can cause these serious conditions, doctors recommend eradicating the infection when it is first discovered. However, finding the ideal treatment regimen for all patients remains challenging.\u003c\/p\u003e\n\n\u003ch2 id=\"study-methods\"\u003eHow the Study Was Conducted\u003c\/h2\u003e\n\n\u003cp\u003eThis was a retrospective cross-sectional study. \"Retrospective\" means the researchers looked back at medical records from the past. \"Cross-sectional\" means they examined a snapshot of patients during a specific time period.\u003c\/p\u003e\n\n\u003cp\u003eThe researchers used the Military Health System Data Repository. This is a centralized database for all patients treated at Department of Defense military treatment facilities worldwide. It includes inpatient and outpatient records for active duty and retired service members and their dependent families.\u003c\/p\u003e\n\n\u003cp\u003eThe study included all adults 18 years or older who tested positive for H. pylori between October 2015 and September 2018. Patients were identified through three types of tests:\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003eStool antigen testing (SAT) — a test that looks for H. pylori proteins in stool samples\u003c\/li\u003e\n  \u003cli\u003eUrea breath test (UBT) — a test that detects H. pylori by measuring a substance in the breath\u003c\/li\u003e\n  \u003cli\u003eImmunoglobulin G (IgG) serology — a blood test that looks for antibodies against H. pylori\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003cp\u003eThe researchers excluded patients with only one diagnostic test. They also excluded patients with positive IgA or IgM serology without positive IgG serology. IgA and IgM are other types of antibodies that are less reliable for diagnosing H. pylori. Patients who only had negative testing were also excluded.\u003c\/p\u003e\n\n\u003cp\u003eThe final analysis included patients with a positive test followed by a negative SAT or UBT after treatment. All patients were treated with an approved regimen.\u003c\/p\u003e\n\n\u003cp\u003eThe researchers gathered data on the antibiotic regimen prescribed, patient age, gender, military status, and geographic location.\u003c\/p\u003e\n\n\u003cp\u003eNo information was available on whether patients appropriately held their proton pump inhibitor (PPI) medicines before testing. PPIs are acid-reducing medications that can affect test results if not stopped before testing. The researchers also did not know how long each treatment regimen lasted.\u003c\/p\u003e\n\n\u003cp\u003eData were analyzed using Microsoft Excel. Patient characteristics were presented using means and standard deviations for continuous variables. Only regimens used more than 10 times in a region were included in the regional analysis. The researchers did not feel confident in performing a Fisher's exact test with numbers less than 10.\u003c\/p\u003e\n\n\u003cp\u003eStatistical tests included Fisher's exact test and the chi-squared test for categorical data. Independent-samples t-test and one-way ANOVA were used for continuous data. Levene's test assessed equality of variances among groups. A P value less than 0.05 was considered statistically significant.\u003c\/p\u003e\n\n\u003cp\u003eThe study was approved by the Institutional Review Board at Walter Reed National Military Medical Center.\u003c\/p\u003e\n\n\u003ch2 id=\"patient-population\"\u003eWho Was Studied\u003c\/h2\u003e\n\n\u003cp\u003eDuring the study period, 20,548 unique H. pylori diagnostic tests were performed. These included:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e7,215 stool antigen tests (SAT)\u003c\/li\u003e\n  \u003cli\u003e362 urea breath tests (UBT)\u003c\/li\u003e\n  \u003cli\u003e12,971 H. pylori IgG serologies\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThe researchers excluded 1,916 IgA-positive and 2,492 IgM-positive serologies. These tests have low sensitivity and specificity for diagnosing H. pylori.\u003c\/p\u003e\n\n\u003cp\u003eThe study identified 2,565 non-active duty patients and 625 active duty patients who had H. pylori testing. Of these, 1,592 non-active duty patients and 374 active duty patients were diagnosed with H. pylori, received treatment, and had eradication testing.\u003c\/p\u003e\n\n\u003cp\u003eAmong the 2,565 non-active duty patients who had testing:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e871 were male (34.0%)\u003c\/li\u003e\n  \u003cli\u003e1,694 were female (66.0%)\u003c\/li\u003e\n  \u003cli\u003eThe average age was 45.2 years (standard deviation 16.2 years)\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eAmong the 625 active duty patients who had testing:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e429 were male (68.6%)\u003c\/li\u003e\n  \u003cli\u003e196 were female (31.4%)\u003c\/li\u003e\n  \u003cli\u003eThe average age was 34.2 years (standard deviation 8.2 years)\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eAmong the 1,592 non-active duty patients who were diagnosed, treated, and had eradication testing:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e532 were male (33.4%)\u003c\/li\u003e\n  \u003cli\u003e1,060 were female (66.6%)\u003c\/li\u003e\n  \u003cli\u003eThe average age was 44.7 years (standard deviation 16.4 years)\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eAmong the 374 active duty patients who were diagnosed, treated, and had eradication testing:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e247 were male (66.0%)\u003c\/li\u003e\n  \u003cli\u003e127 were female (34.0%)\u003c\/li\u003e\n  \u003cli\u003eThe average age was 33.1 years (standard deviation 9.2 years)\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003ePatients were distributed across geographic regions. Among the 2,565 non-active duty patients who had testing:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eSouth: 1,459 patients (56.88%)\u003c\/li\u003e\n  \u003cli\u003eNortheast: 23 patients (0.90%)\u003c\/li\u003e\n  \u003cli\u003eWest: 442 patients (17.23%)\u003c\/li\u003e\n  \u003cli\u003eMidwest: 123 patients (4.80%)\u003c\/li\u003e\n  \u003cli\u003eOverseas: 484 patients (18.87%)\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eAmong the 625 active duty patients who had testing:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eSouth: 376 patients (60.16%)\u003c\/li\u003e\n  \u003cli\u003eNortheast: 13 patients (2.08%)\u003c\/li\u003e\n  \u003cli\u003eWest: 116 patients (18.56%)\u003c\/li\u003e\n  \u003cli\u003eMidwest: 54 patients (8.64%)\u003c\/li\u003e\n  \u003cli\u003eOverseas: 59 patients (9.44%)\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch2 id=\"key-findings\"\u003eKey Findings: Treatment Success Rates\u003c\/h2\u003e\n\n\u003cp\u003eOf the 1,592 non-active duty patients, 1,202 (75.5%) cleared the infection with treatment. Of the 374 active duty patients, 264 (70.6%) cleared the infection with treatment. The difference in clearance rates between active duty and non-active duty patients was statistically significant (P=0.0449).\u003c\/p\u003e\n\n\u003cp\u003eOverall, the most effective treatment regimens were:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eTetracycline-based bismuth quadruple therapy: 85% eradication rate\u003c\/li\u003e\n  \u003cli\u003eTinidazole-based clarithromycin triple therapy: 82% eradication rate\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eIn the non-active duty population, the most effective treatments were:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eTetracycline-based bismuth quadruple therapy: 89% eradication rate\u003c\/li\u003e\n  \u003cli\u003eTinidazole-based clarithromycin triple therapy: 80% eradication rate\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eIn the active duty population, the most effective treatment regimens (used in more than five patients) were:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eTinidazole-based clarithromycin triple therapy: 72% eradication rate\u003c\/li\u003e\n  \u003cli\u003eAmoxicillin-based clarithromycin triple therapy: 72% eradication rate\u003c\/li\u003e\n  \u003cli\u003eTetracycline-based bismuth quadruple therapy: 69% eradication rate\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eClarithromycin triple therapy was the most prescribed regimen. It accounted for 63.9% of all regimens included in the analysis.\u003c\/p\u003e\n\n\u003cp\u003eImportantly, none of the treatment regimens (when used in more than five patients) achieved an eradication rate greater than 90%. Only two regimens in any population achieved eradication rates greater than 80%. These were tetracycline-based bismuth quadruple therapy and tinidazole-based clarithromycin triple therapy.\u003c\/p\u003e\n\n\u003ch2 id=\"regimen-comparisons\"\u003eComparing Treatment Regimens Head-to-Head\u003c\/h2\u003e\n\n\u003cp\u003eThe researchers compared different treatment regimens directly. Several important differences emerged.\u003c\/p\u003e\n\n\u003cp\u003eTetracycline-based bismuth quadruple therapy was superior to amoxicillin-based clarithromycin triple therapy for all patients combined (85% vs. 76%, P=0.01). This difference was also significant for non-active duty patients (89% vs. 77%, P=0.003).\u003c\/p\u003e\n\n\u003cp\u003eHowever, this difference was not seen in active duty patients. There was no significant difference between tetracycline-based bismuth quadruple therapy and amoxicillin-based clarithromycin triple therapy in this group (69% vs. 72%, P=0.82).\u003c\/p\u003e\n\n\u003cp\u003eAll quadruple bismuth therapies combined were superior to all levofloxacin therapies combined. This was true for all patients (80% vs. 64%, P=0.001) and for non-active duty patients (82% vs. 63%, P\u0026lt;0.001).\u003c\/p\u003e\n\n\u003cp\u003eAmoxicillin-based clarithromycin triple therapy was superior to all levofloxacin therapies combined. This was true for all patients (76% vs. 64%, P=0.003) and for non-active duty patients (77% vs. 63%, P=0.002).\u003c\/p\u003e\n\n\u003cp\u003eDoxycycline-based bismuth quadruple therapy had lower eradication rates compared to tetracycline-based bismuth quadruple therapy. However, this difference was only a trend in the data and was not statistically significant (P=0.346).\u003c\/p\u003e\n\n\u003cp\u003eAll levofloxacin regimens had clearance rates inferior to both quadruple therapy and triple therapy across the entire population.\u003c\/p\u003e\n\n\u003ch2 id=\"geographic\"\u003eGeographic Differences in Treatment Success\u003c\/h2\u003e\n\n\u003cp\u003eThe researchers analyzed eradication rates by region using U.S. Census data regions (Northeast, Midwest, South, and West) and overseas locations. Overseas locations were aggregated under Outside the Continental United States (OCONUS).\u003c\/p\u003e\n\n\u003cp\u003eAmoxicillin-based clarithromycin triple therapy cleared the most H. pylori infections across regions. However, this was due to the heavy usage of this regimen across all regions rather than superior efficacy. The success rates for amoxicillin-based clarithromycin triple therapy ranged from 75.1% to 80.3%.\u003c\/p\u003e\n\n\u003cp\u003eMetronidazole-based clarithromycin triple therapy performed better in the Midwest and West than in the South and OCONUS regions.\u003c\/p\u003e\n\n\u003cp\u003eLevofloxacin regimens performed poorly in the West and OCONUS regions. Eradication rates were 52.9% in the West and 63% in OCONUS.\u003c\/p\u003e\n\n\u003cp\u003eClarithromycin-based regimens provided clearance rates nearing 75% in all regions.\u003c\/p\u003e\n\n\u003cp\u003eAlthough trends were identified in differences in geographic eradication rates, none of these achieved the threshold of statistical significance.\u003c\/p\u003e\n\n\u003ch2 id=\"active-vs-nonactive\"\u003eActive Duty vs. Non-Active Duty Patients\u003c\/h2\u003e\n\n\u003cp\u003eThe study found a significant difference in clearance rates between active duty and non-active duty patients. Active duty patients had a 70.6% clearance rate, while non-active duty patients had a 75.5% clearance rate (P=0.0449).\u003c\/p\u003e\n\n\u003cp\u003eThe researchers believe this difference can be explained by differences in the average ages of the groups. Active duty patients were overall more likely to be younger, with a mean age of 34.2 years compared to 45.2 years for non-active duty patients.\u003c\/p\u003e\n\n\u003cp\u003eA previous study on eradication rates and associated clinical factors revealed that age greater than 40 years was significantly associated with higher eradication rates. Although the researchers suspect there may be other factors associated with the difference between these two populations, age alone could explain the difference.\u003c\/p\u003e\n\n\u003cp\u003eNo treatment regimen achieved greater than 80% eradication rates in the active duty population. In fact, no eradication rates were greater than 75% in the active duty population.\u003c\/p\u003e\n\n\u003ch2 id=\"clinical-implications\"\u003eWhat These Findings Mean for Patients\u003c\/h2\u003e\n\n\u003cp\u003eThis study carries significant importance in clarifying the efficacy of various H. pylori treatment regimens across the United States. Updated data have largely been lacking for the past 20 years.\u003c\/p\u003e\n\n\u003cp\u003eThe data support that tetracycline-based bismuth quadruple therapy should be considered as an initial treatment for chronic H. pylori infections across the United States. This regimen had the highest eradication rates in the study.\u003c\/p\u003e\n\n\u003cp\u003eTriple therapy may be considered for patients with no prior exposure to macrolide antibiotics. Macrolides are a class of antibiotics that includes clarithromycin and erythromycin.\u003c\/p\u003e\n\n\u003cp\u003eProvider treatment regimen selections show a clear preference for amoxicillin-based clarithromycin triple therapy. This reflects that H. pylori is primarily managed in the primary care setting throughout the military. There has been low adoption of new recommendations for bismuth quadruple therapy or concomitant therapy. This low adoption is due to increased macrolide resistance in H. pylori strains worldwide.\u003c\/p\u003e\n\n\u003cp\u003eAll levofloxacin regimens had clearance rates inferior to quadruple therapy and triple therapy across the entire population. The reasons for this are unclear. These patients may have already had treatment previously, and there are increasing rates of fluoroquinolone resistance. Fluoroquinolones are a class of antibiotics that includes levofloxacin.\u003c\/p\u003e\n\n\u003cp\u003eMore comparative data about efficacy and susceptibility testing are needed before making firm recommendations regarding fluoroquinolone treatment regimens.\u003c\/p\u003e\n\n\u003cp\u003eThe researchers believe that proof of eradication is important in all settings. This is because clearance rates were below 90% for all regimens studied.\u003c\/p\u003e\n\n\u003cp\u003eAlthough H. pylori infection is a common condition, doctors continue to struggle with adequate treatments. This study further demonstrates this challenge. The study highlights that testing for H. pylori eradication is critical because no regimen had eradication rates above 90%. This is even more important in the active duty population, where no eradication rates were above 75%.\u003c\/p\u003e\n\n\u003ch2 id=\"limitations\"\u003eLimitations: What the Study Could Not Prove\u003c\/h2\u003e\n\n\u003cp\u003eThis study has several limitations that patients and doctors should understand.\u003c\/p\u003e\n\n\u003cp\u003eThe retrospective and de-identified analysis omitted whether patients had been treated previously. It is unclear in patients who had a positive H. pylori IgG whether the serology represented a new infection or an old eradicated one.\u003c\/p\u003e\n\n\u003cp\u003eThe researchers also did not have data on the number of days of treatment. They did not know if patients had appropriately stopped their PPI before eradication testing. PPIs are acid-reducing medications that can affect test results if not stopped before testing. Although this may falsely elevate eradication rates, it likely would not change the relative comparisons between regimens.\u003c\/p\u003e\n\n\u003cp\u003eNo uniform methods of diagnosis and testing of eradication were used. Several regimens were only used by a small number of patients.\u003c\/p\u003e\n\n\u003cp\u003eAlthough this was intended as a nationwide study, military treatment facilities are not evenly distributed throughout the country. Therefore, the study underrepresents the Midwest and Northeast states. The findings may not be broadly applicable in those regions.\u003c\/p\u003e\n\n\u003cp\u003eOCONUS infections are underrepresented in the study. The researchers acknowledge that resistance patterns in Asia are likely different than those in Europe. However, the focus of the study was infections within the United States.\u003c\/p\u003e\n\n\u003cp\u003eThe military population (both active duty and non-active duty) often moves between regions. This may mean someone who tested positive for H. pylori in the South may have recently traveled from the Midwest region.\u003c\/p\u003e\n\n\u003cp\u003eFurthermore, the data do not specify where patients came from in their childhood. This makes further inferences about regional differences difficult because H. pylori is mainly considered a childhood infection.\u003c\/p\u003e\n\n\u003cp\u003eThe study also has several strengths. The researchers drew on a large population of patients with H. pylori who were seen in many different settings. The analysis is less likely to be influenced by more severe patients at tertiary referral centers.\u003c\/p\u003e\n\n\u003cp\u003eThe military health care system is also a relatively closed system. Testing results were in a uniform electronic health record across all settings. Although the study is retrospective, it portrays providers making real-time decisions about therapy rather than those decisions being dictated by a protocol. This realistically represents the primary care setting since the researchers broadly defined a positive result. They strictly defined negative testing results, so the data should have fewer false positives after treatment.\u003c\/p\u003e\n\n\u003ch2 id=\"recommendations\"\u003eRecommendations and Next Steps\u003c\/h2\u003e\n\n\u003cp\u003eBased on this study, several recommendations emerge for patients and healthcare providers.\u003c\/p\u003e\n\n\u003cp\u003eFor patients diagnosed with H. pylori:\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003eDiscuss treatment options with your doctor, including tetracycline-based bismuth quadruple therapy, which had the highest eradication rates in this study.\u003c\/li\u003e\n  \u003cli\u003eAsk about the expected success rate of your chosen regimen. No regimen in this study achieved greater than 90% eradication.\u003c\/li\u003e\n  \u003cli\u003eComplete eradication testing after treatment to confirm the infection is gone. This is critical because no regimen had eradication rates above 90%.\u003c\/li\u003e\n  \u003cli\u003eFollow your doctor's instructions about stopping acid-reducing medications (PPIs) before eradication testing.\u003c\/li\u003e\n  \u003cli\u003eBe aware that active duty service members had lower clearance rates than non-active duty patients in this study.\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003cp\u003eFor healthcare providers:\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003eConsider tetracycline-based bismuth quadruple therapy as an initial treatment for chronic H. pylori infections across the United States.\u003c\/li\u003e\n  \u003cli\u003eConsider triple therapy for patients with no prior exposure to macrolide antibiotics.\u003c\/li\u003e\n  \u003cli\u003eBe cautious about using levofloxacin regimens, as they had inferior clearance rates compared to quadruple therapy and triple therapy.\u003c\/li\u003e\n  \u003cli\u003eEnsure all patients receive eradication testing after treatment.\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003cp\u003eFurther information on susceptibility patterns and treatment efficacy for H. pylori needs to be tracked in the United States on a national and regional basis. Research would ideally include previous antibiotic exposure in patients to inform future antibiotic resistance. Researchers should also evaluate new regimens, such as adding bismuth salts to standard triple therapy or dividing PPI therapy into four times daily dosing.\u003c\/p\u003e\n\n\u003cp\u003eThis is the largest and most geographically widespread H. pylori treatment efficacy study in the United States over 20 years. Many of the last 20 years of study on H. pylori treatment were in single-center (single geography) populations. Multiple studies by Laine and colleagues examined multicenter populations, but these studies were smaller, did not break out efficacy by region, and compared fewer therapy regimens.\u003c\/p\u003e\n\n\u003cp\u003eSimilarly to Alsamman and colleagues and their analysis of H. pylori eradication rates in Rhode Island, this data set from across the United States shows that tetracycline-based bismuth quadruple therapy has the highest eradication rates.\u003c\/p\u003e\n\n\u003c!-- ddn:faq:start --\u003e\n\u003ch2 id=\"ddn-faq\"\u003eFrequently Asked Questions\u003c\/h2\u003e\n\u003ch3\u003eWhat is H. pylori and why does it matter?\u003c\/h3\u003e\n\u003cp\u003eH. pylori is a common bacterium that infects the stomach, usually acquired in childhood. Many people have no symptoms, but the infection can cause chronic stomach inflammation and lead to peptic ulcers, stomach cancer, MALT lymphoma, or functional dyspepsia. Because of these risks, doctors recommend clearing the infection when it is first found.\u003c\/p\u003e\n\u003ch3\u003eDid active duty service members clear the infection less often?\u003c\/h3\u003e\n\u003cp\u003eYes. Among 374 active duty service members, 70.6% cleared the infection, compared with 75.5% of 1,592 non-active duty patients. The difference was statistically significant. Researchers believe it may be explained by age, since active duty patients were younger on average, and older age has been linked to higher clearance rates.\u003c\/p\u003e\n\u003ch3\u003eWhat are the limitations of these findings?\u003c\/h3\u003e\n\u003cp\u003eThis was a retrospective review of records, so researchers did not know prior treatment, treatment duration, or whether patients stopped acid-reducing medicines before testing. Several regimens were used by few patients, and military facilities are not evenly spread across the country, so the Midwest and Northeast were underrepresented. Findings may not apply everywhere.\u003c\/p\u003e\n\u003ch3\u003eI was diagnosed with H. pylori and my doctor prescribed clarithromycin triple therapy — when should I seek a second opinion about my treatment regimen?\u003c\/h3\u003e\n\u003cp\u003eA second opinion is worth considering when the prescribed regimen is clarithromycin triple therapy, since that was the most commonly prescribed option yet no regimen in this population achieved eradication above 90%. Tetracycline-based bismuth quadruple therapy cleared the infection in 85% of patients overall and 89% of non-active duty patients, and it outperformed amoxicillin-based clarithromycin triple therapy (85% vs. 76%). Levofloxacin regimens had lower clearance rates than quadruple or triple therapy. A second opinion can help weigh these alternatives and confirm eradication testing afterward. Diagnostic Detectives Network provides independent expert second opinions.\u003c\/p\u003e\n\u003c!-- ddn:faq:end --\u003e\n\n\u003ch2 id=\"source\"\u003eSource Information\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eOriginal Article Title:\u003c\/strong\u003e MILITARY MEDICINE, 188, 7 8-e2089, 2023 Helicobacter pylori Treatment Regimen Selection and Eradication Rates Across Department of Defense Patients\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors:\u003c\/strong\u003e MAJ Zachary C Junga, MC, USA; CPT Andrew Mertz, MC, USA; CPT Kevin Pak, MC, USA; Manish Singla, MD\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthor Affiliations:\u003c\/strong\u003e Division of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, MD; Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Gastroenterology Service, Landstuhl Regional Medical Center, Landstuhl, Germany; Department of Medicine, Division of Gastroenterology, Naval Medical Center San Diego, San Diego, CA\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003ePublication:\u003c\/strong\u003e Military Medicine, Volume 188, Issue 7-8, July\/August 2023, Pages e2089-e2093\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eDOI:\u003c\/strong\u003e https:\/\/doi.org\/10.1093\/milmed\/usac428\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003ePublished by:\u003c\/strong\u003e Oxford University Press on behalf of the Association of Military Surgeons of the United States\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eNote:\u003c\/strong\u003e This patient-friendly article is based on peer-reviewed research. The views expressed in the original material are those of the authors and do not reflect the official policy or position of the U.S. Government, the Department of Defense, or the Departments of the Army, Navy, and Air Force.\u003c\/p\u003e","brand":"DiagnosticDetectives.Com","offers":[{"title":"Default Title","offer_id":47807304335516,"sku":null,"price":0.0,"currency_code":"USD","in_stock":true}],"url":"https:\/\/diagnosticdetectives.com\/it\/products\/h-pylori-treatment-success-rates-across-u-s-military-health-system-patients-2016-2018","provider":"DiagnosticDetectives.Com","version":"1.0","type":"link"}