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美国胃肠病学会临床实践专家意见：《难治性幽门螺杆菌感染的管理》最新定义：当前指南推荐的一线Hp根除治疗1个或多个疗程失败，即为难治性Hp感染！ Hp首诊根除越发重要！ 一线治疗方案中克拉霉素是否耐药关系到首诊根除能否成功！ 独家创新产品23SrRNA基因突变检测试剂盒能发挥关键作用！ AGA Clinical Practice Update on the Management of Refractory Helicobacter pylori Infection: Expert Review 美国胃肠病协会（AGA）关于难治性幽门螺杆菌感染管理的临床实践更新 导语 内容摘要如下： The purpose of this CPU Expert Review is to provide clinicians with guidance on the management of Helicobacter pylori after an initial attempt at eradication therapy fails, including best practice advice on specific regimen selection, and consideration of patient and systems factors that contribute to treatment efficacy. This Expert Review is not a formal systematic review, but is based upon a review of the literature to provide practical advice. No formal rating of the strength or quality of the evidence was carried out. Accordingly, a combination of available evidence and consensus-based expert opinion were used to develop these best practice advice statements. 本篇CPU专家综述旨在为临床医生提供初次尝试根除治疗失败后幽门螺杆菌管理的指导，包括对特定方案选择的最佳实践建议，以及对有助于治疗效果的患者和系统因素的考虑。本专家综述并非正式的系统性综述，而是基于对文献的回顾，以提供实用建议。没有对证据的强度或质量进行正式评级。因此，综合利用现有证据和基于共识的专家意见，制定了这些最佳实践建议。 难治性Hp感染的最新定义 Refractory H.pylori infection is defined by a persistently positive nonserologic H pylori test result (ie, a breath-, stool-, or gastroscopy-based test), at least 4 weeks after 1 or more completed course(s) of a current guideline-recommended first-line H pylori eradication therapy, and off of any medications, such as proton-pump inhibitors (PPIs), that might impact the test sensitivity. 在当前指南推荐的一线Hp根除治疗1个或多个完整疗程结束后至少4 周，非血清学Hp检测结果持续阳性（即，基于呼吸、美便或胃镜的检测），并排除任何可能影响检测敏感性的药物，如质子泵抑制剂（PPls）抗生素。 最佳实践建议1 The usual cause of refractory Helicobacter pylori infection (persistent infection after attempting eradication therapy) is antibiotic resistance. Providers should attempt to identify other contributing etiologies, including inadequate adherence to therapy and insufficient gastric acid supspanssion. 难治性幽门螺杆菌感染（在尝试根除治疗后持续感染）的常见原因是抗生素耐药。医务人员应确定其他致病原因，包括治疗的依从性不足和胃酸抑制不足。 最佳实践建议2 Providers should conduct a thorough review of prior antibiotic exposures. If there is a history of any treatment with macrolides or fluoroquinolones, then clarithromycin- or levofloxacin-based regimens, respectively, should be avoided given the high likelihood of resistance. By contrast, resistance to amoxicillin, tetracycline, and rifabutin is rare, and these can be considered for subsequent therapies in refractory H pylori infection. 医护人员应完整地了解患者先前的抗生素使用情况。如果有大环内酯类或氟喹诺酮类药物的治疗史，那么鉴于耐药的可能性很高，应分别避免使用克拉霉素或左氧氟沙星类药物。相比之下，对阿莫西林、四环素和利福布汀的耐药性罕见，在难治性幽门螺杆菌感染的后续治疗中可以考虑使用这些药物。 最佳实践建议3 Eradication regimens for H pylori are complex and might not be fully comspanhended by patients. Barriers to adherence should be explored and addressed prior to spanscribing therapy. Providers should explain the rationale for therapy, dosing instructions, expected adverse events, and the importance of completing the full therapeutic course. 幽门螺杆菌的根除方案很复杂，患者可能无法完全理解。在开具治疗处方前，应了解并解决影响患者依从性的障碍。医生应解释治疗的理由、剂量说明、预期的不良事件以及完成全部治疗过程的重要性。 最佳实践建议4 If bismuth quadruple therapy failed as a first-line treatment, shared decision making between providers and patients should guide selection between (a) levofloxacin- or rifabutin-based triple-therapy regimens with high-dose dual proton pump inhibitor (PPI) and amoxicillin, and (b) an alternative bismuth-containing quadruple therapy, as second-line options. 如果铋剂四联疗法作为一线治疗失败，医护人员和患者之间的共同决策应指导在以下两种疗法之间进行选择：(a)以左氧氟沙星或利福布汀为基础的三联疗法方案与大剂量双质子泵抑制剂(PPI)和阿莫西林，以及(b)替代的含铋剂四联疗法，作为二线选择。 最佳实践建议5 When using metronidazolecontaining regimens, providers should consider adequate dosing of metronidazole (1.5–2 g daily in divided doses) with concomitant bismuth therapy, because this may improve eradication success rates irrespective of observed in vitro metronidazole resistance. 在使用含甲硝唑方案时，医护人员应考虑在同时使用铋剂治疗的情况下，给予甲硝唑足够的剂量（每日1.5-2g，分次服用），因为无论体外观察到的甲硝唑耐药性如何，这都可能提高根除成功率。 最佳实践建议6 In the absence of a history of anaphylaxis, penicillin allergy testing should be considered in a patient labeled as having this allergy in order to delist penicillin as an allergy and potentially enable its use. Amoxicillin should be used at a daily dose of at least 2 g divided 3 times per day or 4 times per day to avoid low trough levels. 在没有过敏性休克病史的情况下，对于表示有青霉素过敏的患者应进行青霉素过敏试验，以便排除青霉素过敏，并在可能的情况下使用。阿莫西林的使用剂量为每日至少2g，每日分3次或4次使用。 最佳实践建议7 Inadequate acid supspanssion is associated with H pylori eradication failure. The use of highdose and more potent PPIs, PPIs not metabolized by CYP2C19, or potassium-competitive acid blockers, if available, should be considered in cases of refractory H pylori infection. 抑酸不足与幽门螺杆菌根除失败有关。对于难治性幽门螺杆菌感染的病例，应考虑使用高剂量和更强效的PPIs、不被CYP2C19代谢的PPIs或钾竞争性酸阻断剂（如有）。 最佳实践建议8 Longer treatment durations provide higher eradication success rates compared with shorter durations (eg, 14 days vs 7 days). Whenever appropriate, longer treatment durations should be selected for treating refractory H pylori infection. 与较短的治疗时长相比，较长的治疗时长根除率更高（例如，7天vs. 14天）。在合适的情况下，治疗难治性幽门螺杆菌感染应选择较长的治疗时长。 最佳实践建议9 In some cases, there should be shared decision making regarding ongoing attempts to eradicate H pylori. The potential benefits of H pylori eradication should be weighed carefully against the likelihood of adverse effects and inconvenience of repeated exposure to antibiotics and high-dose acid supspanssion, particularly in vulnerable populations, such as the elderly. 对于正在进行的根除幽门螺杆菌治疗，在某些情况下应该共同决策。应仔细权衡根除幽门螺杆菌的潜在益处与反复使用抗生素和大剂量抑酸的不良反应和不便的可能性，尤其是对老年人等易感人群。 最佳实践建议10 Best Practice Advice 10: After 2 failed therapies with confirmed patient adherence, H pylori susceptibility testing should be considered to guide the selection of subsequent regimens. 在2次治疗失败且患者依从性良好的情况下，应考虑进行幽门螺杆菌易感性检测，以指导后续方案的选择。 最佳实践建议11 Best Practice Advice 11: Compiling local data on H pylori eradication success rates for each regimen, along with patient demographic and clinical factors (including prior non-H pylori antibiotic exposure) is important. Aggregated data should be made publicly available to guide local selection of H pylori eradication therapy. 汇总每个治疗方案的幽门螺杆菌根除率的地方数据，以及患者人口统计学和临床因素（包括之前的非幽门螺杆菌抗生素暴露）是很重要的。应公开汇总数据，以指导当地选择幽门螺杆菌根除疗法。 |
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