Focusing on Helicobacter pylori infection in the elderly

The Aging Stomach: Clinical Implications of H. pylori Infection in Older Adults-Challenges and Strategies for Improved Management

Aging is a multifactorial biological process characterized by a decline in physiological function and increasing susceptibility to various diseases, including malignancies and gastrointestinal disorders. Helicobacter pylori (H. pylori) infection is highly prevalent among older adults, particularly those in institutionalized settings, contributing to conditions such as atrophic gastritis, peptic ulcer disease, and gastric carcinoma. This review examines the intricate interplay between aging, gastrointestinal changes, and H. pylori pathogenesis. The age-associated decline in immune function, known as immunosenescence, exacerbates the challenges of managing H. pylori infection. Comorbidities and polypharmacy further increase the risk of adverse outcomes in older adults. Current clinical guidelines inadequately address the specific needs of the geriatric population, who are disproportionately affected by antibiotic resistance, heightened side effects, and diagnostic complexities. This review focuses on recent advancements in understanding H. pylori infection among older adults, including epidemiology, diagnostics, therapeutic strategies, and age-related gastric changes. Diagnostic approaches must consider the physiological changes that accompany aging, and treatment regimens need to be carefully tailored to balance efficacy and tolerability. Emerging strategies, such as novel eradication regimens and adjunctive probiotic therapies, show promise for improving treatment outcomes. However, significant knowledge gaps persist regarding the impact of aging on H. pylori pathogenesis and treatment efficacy. A multidisciplinary approach involving gastroenterologists, geriatricians, and other specialists is crucial to providing comprehensive care for this vulnerable population. Future research should focus on refining diagnostic and therapeutic protocols to bridge these gaps, ultimately enhancing clinical outcomes and reducing the burden of H. pylori-associated diseases in the aging population.

Knowledge and Practices of Helicobacter pylori Infection Management Among Physicians in Gansu Province, China: A Cross-Sectional Study

BACKGROUND AND AIMS

Physicians' knowledge and practices regarding the diagnosis, treatment, and follow-up of Helicobacter pylori (H. pylori) infection can impact the effectiveness of eradication therapy. This study aimed to investigate the current state of knowledge and practices concerning H. pylori infection management among physicians in Gansu Province, northwest China.

MATERIALS AND METHODS

From October to November 2023, 557 physicians from 14 cities and prefectures in Gansu Province participated in this multicenter cross-sectional study and completed a survey questionnaire.

RESULTS

A total of 519 valid questionnaires were collected. 43.2% of the physicians supported H. pylori screening for high-risk populations or individuals with H. pylori-related diseases. The awareness of target screening populations varied among these physicians, ranging from 69.6% to 98.2%. Most physicians preferred the urea breath test (UBT) as the method for diagnosing H. pylori infection (98.3%) and for follow-up after eradication therapy (98.5%). 89.6% of the physicians preferred bismuth-containing quadruple therapy for initial eradication, with amoxicillin and clarithromycin being the most commonly used antibiotic combination (56.3%). In addition, 84.6% of the physicians indicated that they would inquire about the antibiotic usage history for most patients before treatment, 93.8% would ask patients about their previous eradication history, and 94.2% would inform patients about treatment-related considerations. However, only 43.5%, 27.7%, and 29.7% of the physicians were aware of the high resistance rates of H. pylori to clarithromycin, levofloxacin, and metronidazole, respectively, in Gansu Province. Subgroup analysis revealed that the performance of gastroenterologists, nongastroenterologists, and physicians from different levels of hospitals differed in the diagnosis, treatment, and follow-up of H. pylori infection.

CONCLUSIONS

Knowledge and practices regarding H. pylori infection management among physicians in Gansu Province, China, need further improvement. Strengthening targeted continuing education to increase the overall management level of H. pylori infection is recommended.

The multicenter real-world report of the efficacies of 14-day esomeprazole-based and rabeprazole-based high-dose dual therapy in first-line Helicobacter pylori eradication in Taiwan

BACKGROUND

High-dose dual therapy (HDDT) using proton-pump inhibitors (PPI) and amoxicillin attracted attention for its simplicity and lower adverse event profile. Besides, vonoprazan is not available worldwide. This real-world study aims to compare the efficacy of esomeprazole-based and rabeprazole-based HDDT regimens and to identify clinical factors influencing outcomes.

METHODS

A retrospective study enrolled 346 Helicobacter pylori-infected naïve patients from January 2016 to August 2023. Patients were assigned to either a 14-day esomeprazole-based HDDT (EA-14; esomeprazole 40 mg t.i.d. and amoxicillin 750 mg q.i.d. for 14 days, n = 173) or a 14-day rabeprazole-based HDDT (RA-14; rabeprazole 20 mg and amoxicillin 750 mg q.i.d. for 14 days, n = 173).

RESULTS

Five patients from the EA-14 group and 10 from the RA-14 group were lost to follow-up, resulting in 168 and 163 patients for the per-protocol (PP) analysis, respectively. Eradication rates for the EA-14 and RA-14 groups were 90.2% and 80.9% (P = 0.014) in intention-to-treat (ITT) analysis; and 92.9% and 85.9% (P = 0.039) in PP analysis. Adverse event rates were similar between the two groups (11.9% vs 11.7%, P = 0.944). In multiple logistic regression analysis, age≧60 was associated with eradication failure (P = 0.046) and a trend of significance for smoking (P = 0.060) in the EA-14 group but not in the RA-14 group. A trend of significance was also observed for eradication regimens (EA-14 vs RA-14) (P = 0.071). The antibiotic resistance rates were amoxicillin (2.3%), clarithromycin (14.7%), metronidazole (40.3%), and dual resistance to clarithromycin and metronidazole (7.0%).

CONCLUSIONS

Esomeprazole-based HDDT achieved over 90% eradication rates but rabeprazole-based HDDT, which failed.

Characteristics of Helicobacter pylori Eradication Therapy in Patients 80 Years or Older Living in a Metropolitan Area: A Multicenter Retrospective Study

BACKGROUND

The situation of Helicobacter pylori eradication therapy has been changing over time, owing to increases in antimicrobial-resistant strains, lifestyle improvements, and changes in indications for eradication. In Japan, eradication therapy is now available to all H. pylori-positive patients under the medical insurance system, and the potassium-competitive acid blocker vonoprazan has been used for eradication from 2015. Recently, with the aging of society, opportunities to provide eradication to elderly patients are increasing, but the current status and effectiveness of eradication in elderly patients remains unclear. Therefore, we aimed to investigate the trends of H. pylori eradication in a metropolitan area to determine the factors associated with successful H. pylori eradication in elderly patients older than 80 years.

METHODS

Trends in the eradication rates of patients who received first- or second-line eradication at 20 hospitals in the Tokyo metropolitan area from 2013 to 2023 were investigated.

RESULTS

The eradication rates in the per-protocol analysis were 82.3% (95% confidence interval [CI]: 81.2%-83.2%) for the first-line treatment (n = 6481), and 87.9% (86.9%-88.9%) for the second-line treatment (n = 4899). Multivariate analysis showed that independent factors for successful eradication in the first-line treatment were an age of older than 80 years (OR: 0.606; 95% CI: 0.448-0.822), peptic ulcers (vs. atrophic gastritis: 3.817; 3.286-4.433), and vonoprazan (vs. proton pump inhibiters (PPIs), 3.817; 3.286-4.433), and an age of older than 80 years (0.503; 0.362-0.699) and vonoprazan (1.386; 1.153-1.667) in the second-line treatment.

CONCLUSION

After 2015, the eradication rate of both first- and second-line therapies were maintained at a higher level than before 2015, owing to the use of vonoprazan. As the H. pylori eradication rate in patients older than 80 years was low, an effective strategy for these patients needs to be developed in the future.

Rosacea in Older Adults and Pharmacologic Treatments

Rosacea is a chronic inflammatory skin condition that is often more severe in older patients. The main clinical features are erythema, telangiectasia, and inflammatory lesions of the face. The pathogenesis of this condition is not fully understood but certainly multifaceted. Immune and inflammatory dysregulation, genetics, neurogenic dysregulation, microbiome dysbiosis, and systemic disease have all been implicated in rosacea pathogenesis. As we better understand the various pathways that lead to rosacea, we acknowledge that the different symptoms may have unique underlying triggers and mechanisms. Aging also impacts rosacea diagnosis and treatment. Older adults have more severe rosacea symptoms while also having more sensitive and fragile skin than younger patients; therefore, rosacea treatments for older patients require a balance between delivering adequate potency while also minimizing skin irritation and other adverse effects. Until recently, rosacea diagnoses were based on concrete subtypes that did not necessarily capture each patient's manifestation of rosacea. There is now an emphasis on more personalized phenotype-based diagnoses and treatments, which allows for more emphasis on treating individual symptoms and accounting for the unique characteristics of older patients. Centrofacial erythema is best treated with brimonidine and oxymetazoline, while phymatous change and telangiectasia are best treated with surgery and laser ablation. Treatment for rosacea papules and pustules ranges from topicals, such as azelaic acid, ivermectin, metronidazole, minocycline, and encapsulated benzoyl peroxide, to systemics, such as doxycycline and isotretinoin. It is important to understand these treatments in relation to adverse effects and drug interactions that may specifically arise in older populations to provide optimal care. As we advance in understanding rosacea's pathogenesis and adopt personalized phenotype-based approaches, optimizing care for older patients becomes crucial. Continued research into novel treatments is essential to address their unique needs.

Main Disorders of Gastrointestinal Tract in Older People: An Overview

From a physiological standpoint, aging is a progressive reduction in each organ system’s capacity to maintain homeostasis in the face of illness or stressors. With advancing age, gastrointestinal (GI) symptoms and signs may increase, not only due to the aging processes but also to the superimposed effects of comorbidities, which can badly affect digestive functions (i.e., diabetes, malignancy, etc.) and environmental exposure. In general, gastrointestinal symptoms in older people more often underlie organic pathologies, while GI functional disorders are less frequently diagnosed in this age group. Moreover, gastrointestinal disease can also present in a nuanced and atypical manner, making the diagnostic hypothesis and, consequently, the correct diagnosis and therapy more challenging. In addition, with reference to this age group, the clinical implications of gastrointestinal pathologies can be more severe due to a decreased physiologic reserve, with a higher risk for malnutrition resulting in falls, depression, social isolation, and a deterioration of functional status. In this review, we focused on the most frequent GI tract disorders, highlighting the main age-related changes, their epidemiological, pathophysiological and clinical implications, and any differences with younger patients.

Epidemiology of Helicobacter pylori Resistance to Antibiotics (A Narrative Review)

Helicobacter pylori (H. pylori) is the most common bacterial infection worldwide and one of the main etiological factors of chronic gastritis, peptic ulcer disease, and stomach neoplasms. The mass application of antibiotics without testing, especially during the last years of the pandemic of SARS-CoV-2, could lead to a dramatic increase in antibiotic resistance and reduced effectiveness of eradication regimens for H. pylori infection. The epidemiology of H. pylori resistance to antibiotics still has unclear mechanisms. Antibiotic policy should be intensified to optimize treatment, and regular monitoring of resistance of H. pylori in different geographical regions should be conducted. Individualized treatment according to susceptibility testing is strongly advisable, and the best treatment regimens should be selected. The mutations in the genes encoding the antibiotic target protein are significant risk factors for H. pylori resistance. Iatrogenic errors in diagnosis and prescribing treatment for the failure of H. pylori eradication are other important risk factors. The low level of awareness and compliance with the correct treatment influence the rate of H. pylori resistance. Epidemiological surveillance of antibiotic resistance and the adoption of new treatment strategies are needed. The discovery of an efficient vaccine against H. pylori could reduce the pressure of the world's growing antibiotic resistance.