Editorial: H. pylori Guidelines: To Implement and How—That Is the Question

The importance of Helicobacter pylori infection progressed from diagnostic curiosity some 40 years ago to clinical priority after being categorised by IARC as a Group 1 carcinogen for gastric adenocarcinoma [1, 2]. It is now 30 years since the first European Consensus Guideline [3] on the management of H. pylori , followed closely by the first Asian Pacific Guideline [4].

Following these meetings, a worldwide survey [5] of 470 primary care physicians found the guidelines generally effective, but with significant regional disparities in approach to diagnosis and treatment, especially drug resistance and persistent infections. Subsequently, several large‐scale international registries (e.g., European Hp‐EuReg, Asian Pacific APAGE) [6, 7] have been published and findings translated to clinical practice through regularly updated guidelines which continue to evolve.

Quach et al. [8] presented a survey among 92 globally selected senior clinicians with extensive experience of managing H. pylori infection. They highlight significant gaps in guideline implementation resulting in failure to attain eradication targets of > 90%, usually from suboptimal approaches to diagnosis and treatment selection, and inadequate follow‐up. Despite antimicrobial resistance, they found continued reliance on empiric treatment regimens as a serious barrier to success. Their suggested approach requires implementation of structured, patient‐centred care bringing management strategies within antimicrobial stewardship programs and fostering co‐ordinated strategies to close the gap between evidence‐based guidelines and real‐world clinical practice.

Guidelines for managing H. pylori infection have undoubtedly had a positive effect as evidenced by recent large surveys and a number of publications from Hp‐EuReg [6]. These confirm that updated evidence is translated into clinical practice. However, results are approximating a plateau of what can be achieved through guidelines alone and guideline methodology emphasises implementation as a major challenge [9].

To achieve substantial further progress, healthcare systems must fund infrastructure to implement formal policies of antimicrobial stewardship, with availability of regional antimicrobial sensitivity testing, and accurate diagnostic tests including PCR genotype susceptibility testing. This would more accurately guide treatment choice, whether initial or repeat. Formal follow‐up testing to ensure cure of infection is particularly important in high‐risk patients who should also have long‐term follow‐up. In addition to securing formal diagnostic services, there must be availability of recommended drugs for combination therapies to successfully eradicate H. pylori infection from the highly acidic human stomach. Acid suppression is obligatory (pH > 6) for success and is only achievable by P‐CABs (not PPIs). Moreover, there is real promise for properly developed dual therapies with efficacy, simplicity and improved compliance in a program of antibiotic stewardship in accord with WHO recommendations [10]. Since P‐CABs have been available for a decade, it is problematic that they are not more widely approved and available.

When clinical trials drive the need for improving management, changes in physician practice must be matched and supported by investment and the provision of necessary complementary health care resources such as microbiology services, organisational structures and workflows. The appropriate paths to implementation remain our major challenge and should be considered by current and future guideline groups to ensure the best way forward.

Author Contributions

Richard H. Hunt: conceptualization, writing – original draft.

Funding

The author has nothing to report.

Linked Articles

This article is linked to Quach et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70798 and https://doi.org/10.1111/apt.70934.

Hunt R. H., “Editorial: H. pylori Guidelines: To Implement and How—That Is the Question,” Alimentary Pharmacology & Therapeutics 64, no. 6 (2026): 833–834, 10.1111/apt.70928.

Data Availability Statement

The author has nothing to report.