Objective: A global consensus meeting was held to review current evidence and knowledge gaps and propose collaborative studies on population-wide screening and eradication of Helicobacter pylori for prevention of gastric cancer (GC). Methods: 28 experts from 11 countries reviewed the evidence and modified the statements using the Delphi method, with consensus level predefined as ≥80% of agreement on each statement. The Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach was followed. Results: Consensus was reached in 26 statements. At an individual level, eradication of H. pylori reduces the risk of GC in asymptomatic subjects and is recommended unless there are competing considerations. In cohorts of vulnerable subjects (eg, first-degree relatives of patients with GC), a screen-and-treat strategy is also beneficial. H. pylori eradication in patients with early GC after curative endoscopic resection reduces the risk of metachronous cancer and calls for a re-examination on the hypothesis of ‘the point of no return’. At the general population level, the strategy of screen-and-treat for H. pylori infection is most cost-effective in young adults in regions with a high incidence of GC and is recommended preferably before the development of atrophic gastritis and intestinal metaplasia. However, such a strategy may still be effective in people aged over 50, and may be integrated or included into national healthcare priorities, such as colorectal cancer screening programmes, to optimise the resources. Reliable locally effective regimens based on the principles of antibiotic stewardship are recommended. Subjects at higher risk of GC, such as those with advanced gastric atrophy or intestinal metaplasia, should receive surveillance endoscopy after eradication of H. pylori . Conclusion: Evidence supports the proposal that eradication therapy should be offered to all individuals infected with H. pylori . Vulnerable subjects should be tested, and treated if the test is positive. Mass screening and eradication of H. pylori should be considered in populations at higher risk of GC.

Objective: Helicobacter pylori infection is mostly a family-based infectious disease. To facilitate its prevention and management, a national consensus meeting was held to review current evidence and propose strategies for population-wide and family-based H. pylori infection control and management to reduce the related disease burden. Methods: Fifty-seven experts from 41 major universities and institutions in 20 provinces/regions of mainland China were invited to review evidence and modify statements using Delphi process and grading of recommendations assessment, development and evaluation system. The consensus level was defined as ≥80% for agreement on the proposed statements. Results: Experts discussed and modified the original 23 statements on family-based H. pylori infection transmission, control and management, and reached consensus on 16 statements. The final report consists of three parts: (1) H. pylori infection and transmission among family members, (2) prevention and management of H. pylori infection in children and elderly people within households, and (3) strategies for prevention and management of H. pylori infection for family members. In addition to the ‘test-and-treat’ and ‘screen-and-treat’ strategies, this consensus also introduced a novel third ‘family-based H. pylori infection control and management’ strategy to prevent its intrafamilial transmission and development of related diseases. Conclusion: H. pylori is transmissible from person to person, and among family members. A family-based H. pylori prevention and eradication strategy would be a suitable approach to prevent its intra-familial transmission and related diseases. The notion and practice would be beneficial not only for Chinese residents but also valuable as a reference for other highly infected areas.

Background: Helicobacter pylori resistance to antibiotics commonly used in eradication regimens is increasing dramatically in many locations; new strategies are needed to manage this infectious disease. Objective: This study’s aim was to collect and update information on antibiotic resistance (AR) rates in H. pylori as well as current strategies for H. pylori management, including public health issues, from a global perspective. Design: An international survey was conducted in 31 countries on 6 continents to address key issues concerning the management of H. pylori -related AR. Individual aspects included the prevalence of AR for specific antibiotics, antibiotic susceptibility testing (AST) in different healthcare systems, availability of drugs, reimbursement issues and strategies for H. pylori AR surveillance. Results: Resistance to the most effective antibiotics used in H. pylori eradication regimens is increasing globally, with clarithromycin and levofloxacin resistance exceeding 15% in 24/31 and 18/31 countries, respectively. Amoxicillin remains an exception, with resistance rates under 2% in 14/31 countries; though African countries have reported amoxicillin resistance rates of over 90%. Bismuth-based treatment regimens are the most effective and are recommended as first-line treatment in several countries. However, more than 1 billion inhabitants worldwide have no access to bismuth-based regimens. PCR-based tests for AR are used in 16/26 countries but are reimbursed in only 4, while next generation sequencing-based tests are available, but not reimbursed, in 3 countries. In 22/26 countries only culture-based methods are available (reimbursed in 9/26 countries). AR surveillance programmes have only been established in 4/26 countries. Therefore, in most countries, empirical therapy with the most effective local regimen available locally is practiced. Conclusion: The dramatic global rise in H. pylori antibiotic resistance requires an urgent revision of current management strategies. Possible solutions include AST-based selection of effective treatment regimens, identification of novel combinations of existing drugs and exploration of novel drugs.

Background and Aims: The efficacy of PPI‐amoxicillin dual therapy (high‐dose dual therapy) in the eradication of Helicobacter pylori is controversial. We aimed to investigate whether PPI‐amoxicillin dual therapy is effective.Methods: We searched several publication databases for randomized controlled trials (RCTs) that compared PPI‐amoxicillin dual therapy with controls up to March 2019. Meta‐analyses of eradication rates were performed using random‐effects models.Results: Data from twelve RCTs including 2249 patients suggested that PPI‐amoxicillin dual therapy and the current mainstream guidelines‐recommended therapies achieved similar efficacy (83.2% vs 85.3%, risk ratio [RR]: 1.00, 95% CI 0.97‐1.03, intention‐to‐treat analysis), (87.5% vs 90.1%, RR: 0.98, 95% CI 0.95‐1.02, per‐protocol analysis), and compliance (94.3% vs 93.5%, RR: 1.11, 95% CI 0.78‐1.59), but side effects were less likely in the dual therapy (12.9% vs 28.0%, RR: 0.53, 95% CI 0.37‐0.76). Further subgroup analyses showed that the seven RCTs (1302 patients) that reported antimicrobial susceptibility test results also showed that PPI‐amoxicillin dual therapy and the current guidelines‐recommended therapies achieved similar efficacy, and PPI‐amoxicillin dual therapy was as effective for rescue therapy (RR: 0.97, 95% CI 0.89‐1.05) as for first‐line treatment (RR: 0.97, 95% CI 0.93‐1.02).Conclusions: Compared with the current mainstream guidelines‐recommended therapies, PPI‐amoxicillin dual therapy has the same efficacy and compliance, and generally PPI‐amoxicillin dual therapy causes fewer side effects.

Objective: To convene a global consensus on Helicobacter pylori ( H pylori ) screening and eradication strategies for gastric cancer prevention, identify key knowledge gaps and outline future research directions. Methods: 32 experts from 12 countries developed and refined consensus statements on H pylori management, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to assess evidence and the Delphi method to achieve ≥80% agreement. Results: Consensus was achieved on 28 statements. Eradication of H pylori , the primary cause of gastric cancer, reduces the risk of gastric cancer across all age groups, with the greatest risk reduction before the onset of premalignant conditions. H pylori eradication also promotes ulcer healing, prevents ulcer recurrence and reduces the risk of NSAID/aspirin related ulcers. H pylori transmission primarily occurs within families, making family based approaches promising for reducing spread and improving treatment outcomes. H pylori screening should prioritise high risk populations. ¹³ C-urea breath test or monoclonal stool antigen tests are preferred. Validated serological testing is a feasible alternative in low prevalence settings when followed by confirmatory non-serological testing. Integrating H pylori screening into existing health programmes may optimise patient adherence and resource utilisation. Empiric eradication treatment, especially bismuth quadruple therapy, is recommended in regions with high H pylori antibiotic resistance for conventional antibiotics. Potassium competitive acid blocker based regimens are alternatives. Confirmatory testing is strongly recommended to ensure H pylori eradication. Endoscopy is suggested for H pylori infected individuals with a high risk of gastric cancer and/or alarm features. H pylori eradication does not increase the risk of reflux oesophageal adenocarcinoma. Long term disruptions to the microbiota and resistome, as well as the environmental impact of increased antibiotic use, warrant further investigation. The development of an H pylori vaccine remains an unmet need, as does the establishment of a risk stratified approach informed by advanced genetic research. Conclusion: H pylori eradication is an effective prevention strategy for gastric cancer that should be offered to all infected adult individuals. Future research should prioritise determining the optimal timing for screening, evaluating long term individual and population outcomes, as well as identifying more precise risk stratification parameters.