Authors’ reply

Sotirios D. Georgopoulosa, Pericles Apostolopoulosb, Spyridon Michopoulosc, Theodore Rokkasd

Athens Medical, P. Faliron Hospital; NIMTS Hospital, Athens; Alexandra Hospital, Athens; Henry Dynant Hospital, Athens, Greece

aGI Department Athens Medical, P. Faliron Hospital, P. Faliron, Greece; bGI Department NIMTS Hospital, Athens, Greece; cGI Department Alexandra Hospital, Athens, Greece; dGI Department Henry Dynant Hospital, Athens, Greece

Correspondence to: Sotirios D. Georgopoulos, MD, FEBGH, AGAF, Director, GI Department. Athens Medical, P. Faliron Hospital, 144 Kountouriotou Str.,18535 Piraeus, Greece, e-mail:
Received 3 February 2020; accepted 5 February 2020; published online 27 March 2020
© 2020 Hellenic Society of Gastroenterology

We read with great interest the letter by Papaefthymiou et al [1] concerning the Greek National Consensus on Helicobacter pylori (H. pylori) infection [2]. We certainly agree with the authors that over the past years in order to overcome the fast-growing antibiotic resistance of H. pylori infection worldwide, an “add-on” strategy has been adapted, and that this is more obvious in countries like Greece, where bismuth salts are not commercially available. Thus, novel H. pylori eradication regimens, with a more targeted pathophysiological approach, are under evaluation and we are awaiting with great interest the results of the ongoing clinical trials.

Eradication of H. pylori infection has traditionally relied on empiric therapeutic regimens, since the need for endoscopy and the limited availability of culture, in most countries including Greece, have rendered the susceptibility-guided treatment option impractical or even unfeasible. Moreover, a recent randomized study showed that susceptibility-guided therapy in a high-resistance area was equally effective as a local empirical regimen [3], while another randomized study failed to reveal superiority of genotypic resistance-guided therapy over a properly designed empirical treatment for eradication of refractory H. pylori infection [4]. For these reasons, the Greek consensus has stated (Statement 26) that culture and antimicrobial susceptibility testing is not recommended before first-line therapy, and that susceptibility-guided therapy should be provided as a rescue treatment, especially after second-line treatment has failed.

On the other hand, the effect of vitamin D (vitD) on H. pylori infection and eradication rates has been widely investigated recently [5]. VitD, apart from its well-known role in calcium and phosphorus metabolism, has been proven to be potent immune modulator of the adaptive immune system, stimulating the innate immune response upon infection [6]. Based on these data, several clinical studies have illustrated that vitD analogs may have anti-H. pylori antimicrobial effects. Cytological research has also found that vitD3 decomposition product 1 can lyse H. pylori bacterial cells by inducing the collapse of the cell membrane [7]. However, the correlation with vitD has not been fully clarified and studies of the impact of serum vitD levels on H. pylori eradication were mostly observational or retrospective and of small sample size [8-10]. Therefore, well-designed randomized controlled prospective studies with a large sample size are needed. We were delighted to hear that a national multicenter study on the relationship between vitD and H. pylori was recently launched and we are awaiting the results.


1. Papaefthymiou A, Doulberis M, Polyzos SA, Kountouras J. National consensus on Helicobacter pylori infection:the next-day challenge. Ann Gastroenterol 2020;33:324.

2. Georgopoulos SD, Michopoulos S, Rokkas T, et al. Hellenic consensus on Helicobacter pylori infection. Ann Gastroenterol 2020;33:105-124.

3. Chen Q, Long X, Ji Y, et al. Randomised controlled trial:susceptibility-guided therapy versus empiric bismuth quadruple therapy for first-line Helicobacter pylori treatment. Aliment Pharmacol Ther 2019;49:1385-1394.

4. Liou JM, Chen PY, Luo JC, et al;Taiwan Gastrointestinal Disease and Helicobacter Consortium. Efficacies of genotypic resistance- guided vs empirical therapy for refractory Helicobacter pylori infection. Gastroenterology 2018;155:1109-1119.

5. Han C, Ni Z, Yuan T, et al. Influence of serum vitamin D level on Helicobacter pylori eradication:a multi-center, observational, prospective and cohort study. J Dig Dis 2019;20:421-426.

6. Baeke F, Takiishi T, Korf H, Gysemans C, Mathieu C. Vitamin D:modulator of the immune system. Curr Opin Pharmacol 2010;10:482-496.

7. Wanibuchi K, Hosoda K, Ihara M, et al. Indene compounds synthetically derived from vitamin D have selective antibacterial action on Helicobacter pylori. Lipids 2018;53:393-401.

8. Yildirim O, Yildirim T, Seckin Y, Osanmaz P, Bilgic Y, Mete R. The influence of vitamin D deficiency on eradication rates of Helicobacter pylori. Adv Clin Exp Med 2017;26:1377-1381.

9. Huang B, Yan S, Chen C, Ye S. Effect of 25-hydroxyvitamin D on Helicobacter pylori eradication in patients with type 2 diabetes. Wien Klin Wochenschr 2019;131:75-80.

10. El Shahawy MS, Hemida MH, El Metwaly I, Shady ZM. The effect of vitamin D deficiency on eradication rates of Helicobacter pylori infection. JGH Open 2018;2:270-275.


Conflict of Interest: None