Reply

We thank Drs Chey, Howden, and Leontiadis for their comments. We apologize for the confusion regarding the confirmation of cure; this was only one of many stimuli for the Houston Consensus Conference, which was both planned and completed before the publication of the American College of Gastroenterology (ACG) guideline.^1,2 We were pleased to see that the 2017 ACG version had corrected that error from the earlier ACG guideline.

They also questioned the recommendation in statement 7 that patients who are first-generation immigrants from high-prevalence areas be tested for Helicobacter pylori infection. Statement 7 specifically focuses on patients and not universal screening, the latter, however, has become of increased interest as a cost-effective means of eliminating gastric cancer.^3,4 Rather, statement 7 related to the doctor–patient relationship, the likelihood of infection, of transmission within the family, and of the risk of H pylori–related disease being similar to that of their region of origin.²

The Houston consensus dealt with H pylori primarily as an infectious disease and to discussed treatment in terms of the principles of antimicrobial therapy and antimicrobial stewardship. In contrast, the ACG and Toronto guidelines relied on meta-analyses of studies from populations who were not comparable because of differences in resistance patterns, doses, durations of therapy, or proton pump inhibitor potency.^5,6 The ACG guideline even described the continued use of the same failed standard triple therapy for 15 years. Neither the ACG nor the Toronto guidelines acknowledged the issue of antimicrobial misuse and poor antimicrobial stewardship. For example, amoxicillin, clarithromycin, and a third antibiotic combination resulted in all patients receiving at least 1 unneeded antibiotic, leading to an estimated 18 tons of unneeded clarithromycin or metronidazole (class I carcinogen) per 1 million treatments.⁷