What is new from the European Maastricht VI/Florence consensus on H. pylori

Research on H. pylori continues at a relentless pace also 40 years after its discovery and regular updates are essential for adapting and optimizing the clinical management of the infection. In this sixth edition of the Maastricht/Florence Consensus Report progress made over the past 5 years is covered and critically analysed for translation into clinical practice. It is intended as a general guide in H. pylori management but presupposes to be adapted to specific regional peculiarities and needs whenever required.
Forty-one experts from 29 countries representing a global community, examined the new data related to H. pylori infection for their clinical impact in five working groups: (1) Indications / Associations, (2) Diagnosis, (3) Treatment, (4) Prevention / Gastric cancer, (5) H. pylori and gut microbiota. The results were summarized totalling in 87 statements supported by varying levels of evidence and recommendations.

A small selection of relevant clinical statements and considerations from the original manuscript released in Gut in august (1) is presented here :
- According to the original definition from the Kyoto Consensus conference of H. pylori gastritis as an infectious disease (2) it is reemphasized that whenever H. pylori is diagnosed eradication is recommended also in the absence of symptoms and complications
- H. pylori testing and treatment are advisable for high-risk patients who are already on long-term aspirin and for naïve patients starting long-term NSAID therapy. In long term PPI users gastritis improves after eradication

- H. pylori treatment is challenged by the continuously rising antibiotic resistance and careful selection of first line and rescue therapies is required.
- Molecular methods (real time-PCR, whole genome sequencing and digital PCR) allow detection of H. pylori mutations associated with resistance to clarithromycin, levofloxacin, tetracycline and rifampicin.

- When using clarithromycin and levofloxacin in H. pylori eradication regimens individual antibiotic susceptibility testing (if available) should be performed

- When using empirical therapy in presence of clarithromycin resistance >15 % or if resistance is unknown Bismuth based quadruple (BQT)regimen is the first option.
- If BQT is not available concomitant therapy (PPI plus 3 antibiotics) should be considered.
- Potassium competitive acid blockers (P-CABS, ie Vonoprazan) are superior to PPI-based triple therapies in patients with evidence of antimicrobial resistant H. pylori infections
- H. pylori infection is the primary aetiological factor for gastric adenocarcinoma including proximal gastric cancer. H. pylori infection plays an aetiological role as well in a subset of adenocarcinoma of the Gastro-oesophageal Junction zone
- H. pylori eradication offers the chance for gastric cancer prevention at any age in adulthood. The magnitude of the benefit decreases with age
- Screening modalities for gastric cancer prevention combined with colorectal cancer screening is an opportunity
- Follow up at regular intervals, and by use of endoscopic biopsy protocols, is mandatory in patients with severe atrophic gastritis (OLGA 3/4)
- Broad use of H. pylori eradication therapies for the purpose of gastric cancer prevention does not lead to an increase in other severe pathologies

- The role of H. pylori infection and the effect of eradication therapy is addressed in its actual and potential interactions with other microbiota in the upper and lower digestive tract

Looking forward to the years to come we will face the challenges of better controlling the rising antibiotic resistance and make best use of opportunities with new , including molecular, testing and optimized therapies that will include stronger acid suppressants (ie P-CABS). A wishful thought is the development of microbial fighters as alternatives or in support of antibiotics in H. pylori eradication regimens.
In our mission to provide an H. pylori free healthy stomach to all we will have to deal and solve a complexity of pro- an con-issues.