Antibiotics for Dyspepsia: Hp, SIBO, IMO, or Something Else?

Excerpt

Since the dawn of humankind, the gastric pathogen Helicobacter pylori (Hp) has coexisted with humanity, migrating and dispersing throughout the globe following our footprints (or more precisely, our stomachs). Although Its contribution to gastric cancer pathogenesis is unquestioned, accounting for almost 75% of the global burden of gastric cancer [1], its involvement in non-ulcerative dyspepsia is somewhat disputed. A recent meta-analysis reported that the association of dyspepsia with Hp is rather modest with an OR = 1.18; 95% (CI 1.04–1.33) [2]. Nevertheless, for patients with dyspepsia, a routine test and treat strategy for Hp is commonly employed. As expected, the efficacy is somewhat modest with a NNT of 9 for symptom relief [3]. In practice, symptoms typically recur after treatment despite documented eradication of the organism, with symptom relief for over three months achieved in only 30% of patients [3]. There has always been a question as to whether the eradication of Hp is what improves symptoms or rather that the improvement is due to the modulation of other pathological gut microbes. The latter may explain the high symptom recurrence rate after Hp treatment given that the recurrence rate of Hp itself is low [4]. …