Current progress toward eradicating Helicobacter pylori in East Asian countries: Differences in the 2013 revised guidelines between China, Japan, and South Korea

Table 1 Indications for Helicobacter pylori eradication in 2013 guidelines

	Indications
China	Strongly recommended
	Peptic ulcer (regardless of activeness or complications)
	Gastric MALT lymphoma
	Recommended
	Chronic gastritis with dyspepsia
	Chronic gastritis with mucosal atrophy/erosion
	Early gastric cancer resected endoscopically or by subtotal gastrectomy
	Long-term use of proton pump inhibitor
	Family history of gastric cancer
	Planning to take long-term NSAIDs (including low-dose aspirin)
	Iron deficiency anemia of unknown causes
	Idiopathic thrombocytopenic purpura
	Other H. pylori-related diseases (lymphocytic gastritis, gastric hyperplastic polyps, Ménétrier disease, etc.)
	Requested by individual patient
Japan	Approved by the Japanese national health insurance system
	Peptic ulcer disease
	After resection of early gastric cancer
	Gastric MALT lymphoma
	Idiopathic thrombocytopenic purpura
	H. pylori-related gastritis
South Korea	Strongly recommended
	Peptic ulcer disease
	Low-grade gastric MALT lymphoma
	After resection of early gastric cancer
	Recommended
	Chronic atrophic gastritis or intestinal metaplasia
	Family history of gastric cancer
	Functional dyspepsia
	Long-term aspirin/NSAIDs medication with history of peptic ulcer disease
	Idiopathic thrombocytopenic purpura

H. pylori: Helicobacter pylori; MALT: Mucosa-associated lymphoid tissue; NSAIDs: Nonsteroidal anti-inflammatory drugs.

Table 2 Diagnostic methods for Helicobacter pylori infection in 2013 guidelines

		China	Japan	South Korea
For initial diagnosis	Non-invasive methods	Urea breath test	Serum antibody test	Serum antibody test
		Stool antigen test	Urea breath test	Urea breath test
			Stool antigen test	Stool antigen test
	Invasive methods	Rapid urease test	Rapid urease test	Rapid urease test
		Histology	Histology	Histology
		Culture	Culture
Follow-up test after eradication	Non-invasive methods	Urea breath test	Serum antibody test1	Urea breath test
		Stool antigen test	Urea breath test	Stool antigen test
			Stool antigen test
	Invasive methods	Rapid urease test	Rapid urease test	Rapid urease test
			Histology	Histology
			Culture

¹In Japan, a decrease relative to the initial antibody titer of more than 50% after 6-12 mo is considered to be the most accurate method for determining successful eradication. Since the Japanese national health insurance system covers 2 of 3 non-invasive tests at the same time, either “serology with the urea breath test” or “serology with the stool antigen test” is usually performed before and after Helicobacter pylori eradication.

Table 3 Regimens for Helicobacter pylori eradication in 2013 guidelines

	China	Japan	South Korea
First-line treatment1	Amoxicillin 1 g (or metronidazole 400 mg), clarithromycin 500 mg, and PPI twice daily for 7-14 d	Amoxicillin 750 mg, clarithromycin 200 mg (or 400 mg), and PPI twice daily for 7 d	Amoxicillin 1 g, clarithromycin 500 mg, and PPI twice daily for 7-14 d
Second-line treatment	Bismuth 220 mg, tetracycline 750 mg, metronidazole 400 mg twice, and PPI twice daily for 10 or 14 d	Amoxicillin 750 mg, metronidazole 250 mg, and PPI twice daily for 7 d	Bismuth 120 mg four times, tetracycline 500 mg four times, metronidazole 500 mg thrice, and PPI twice daily for 7-14 d

¹In China and South Korea, first-line treatment can be passed directly to second-line treatment using bismuth-based quadruple therapy in cases with a high clarithromycin resistance rate (> 15%-20%). PPI: Proton pump inhibitor.

Table 4 Different characteristics of 2013 guidelines in three countries

	Country	Notable differences in characteristics
Indication for eradication	China	Strong recommendations do not include after resection of EGC. Intestinal metaplasia is not included in the indications
	Japan	All infected subjects are included as “H. pylori-related gastritis”
		Focus is on preventing dissemination
	South Korea	Strong recommendations include only peptic ulcer disease, gastric MALT lymphoma, and after resection of EGC
Diagnostic method	China	Serology is not recommended
		Only the urea breath test is recommended after eradication
		Invasive tests are not recommended after eradication
	Japan	Either two noninvasive tests or one invasive test is recommended
		A decrease relative to the initial serum antibody level of more than 50% after 6-12 mo is considered the most reliable method
	South Korea	Bacterial culture is not included
Treatment regimen	China	Due to the high resistance to the antibiotics metronidazole, clarithromycin, and tetracycline, an alternative regimen is recommended
		First-line treatment can be omitted in cases of clarithromycin resistance
	Japan	Lower dose of antibiotics for shorter duration (7 d) than other countries
		There is neither 14 d nor bismuth-based regimen in the first-line and second-line treatment
	South Korea	First-line treatment can be omitted in cases of clarithromycin resistance

EGC: Early gastric cancer; H. pylori: Helicobacter pylori; MALT: Mucosa-associated lymphoid tissue.