In Africa, the burden of H. Pylori infection is high with a prevalence of 70.1% [1]. Dyspepsia, gastritis, mucosa-associated lymphoid tissue lymphoma, peptic ulcer disease and gastric adenocarcinoma are some of the pathological consequences of H. Pylori [2]. In developed high-income countries, the burden of H. Pylori infection may be reduced by proper guided treatment and an accurate diagnosis [3]. The American College of Gastroenterology, European H. Pylori and Microbiota Surgery Group and Asia-Pacific Association of Gastroenterology have reached consensus guidelines on the treatment and diagnosis 1 of H. Pylori [4-6]. However, there are no consensus guidelines for treatment and diagnosis of H. Pylori infection in Africa. The need to conceptualize treatment protocols is important as different countries in Africa have used different forms of treatment for the management of H. Pylori and use non-invasive and invasive methods for diagnosis [6] In Africa, antibiotic resistance results in an increase in treatment failures and inadequate health-care systems are some of the challenges faced in these populations. In this review the treatment and diagnosis of H. Pylori in Africa are discussed with the aim that this study will facilitate a consensus working plan for treatment of this infection in Sub-Saharan Africa [5,6].

There are non-invasive and invasive methods which are used for diagnosing H. Pylori infection [7]. Invasive techniques include the rapid urease test, endoscopy and histology however there is variation in their sensitivity and specificity. There have been technological improvements in endoscopy which have resulted in a more expedient diagnosis [7]. The gold standard used to detect H. Pylori has been histology. The location in the stomach and the number of retrieved biopsies dictates the accuracy of this investigation [8]. The rapid urease test has 80-90% specificity and 95% sensitivity and is reliable in the diagnosis of H. Pylori [8,9]. Culture of H. Pylori from stool samples and from biopsies has the advantage in that it determines the antibiotic sensitivity to isolates of H. Pylori [10]. The detection of anti-H. Pylori IgG in urine or blood is a low-sensitivity serological test and cannot distinguish inactive from active infection [11]. Another gold standard diagnostic method is culture of H. Pylori from stool samples and from biopsies obtained at gastroscopy [12]. A technique used in the detection of H. Pylori is the use of Fluorescence in situ hybridization is a technique used for the detection of clarithromycin-sensitive H. Pylori. The stool antigen test is a noninvasive method used to screen for H. Pylori [13]. The most accurate method which is noninvasive and used for detecting H. Pylori is the urea breath test [13]. The urea breath test is used for assessing the eradication of H. Pylori following treatment [14]. The urea breath test depends on the hydrolysis of nonradioisotope-labelled 13C or isotope-labelled urea (14C) of urease from H. Pylori [15]. The specificity is 95.1% and sensitivity was 98.1% with the 13Carbon urea breath test [16].

In East Africa, poor health infrastructure, poor standards of living, and a few qualified health care personnel limit the usage of some of these methods in diagnosis [17]. Lowering the burden of infection in Africa requires accurate and cost-effective methods which have been used in Africa to reduce gastric adenocarcinoma and peptic ulcer disease which are associated with H. Pylori [17].

In Europe and the USA, over the last 100 years there has been a decline in H. Pylori infection [18]. In children, noninvasive and invasive forms of diagnosis of H. Pylori [18] can be made using gastroscopy, histology, culture, rapid urease test and the monoclonal serum antigen test (Hp Star) [19]. An H. Pylori prevalence of 66.12% has been observed in Algeria [19]. Stool antigen testing reached diagnostic consensus and is commonly performed in Egypt. Widely used diagnostic modalities include atrophy of the gastric mucosa, presence of H. Pylori histologically, and the urea breathe test. The serum antigen test and histology were the previous two commonly used modalities [20,21].

In Tunisia a combination of gastroscopy, culture, histology, polymerase chain reaction (PCR), and the rapid urease test is used for diagnosis of H. Pylori [22]. In Libya, ELISA serological methods are used for detecting anti-H. Pylori IgG [23]. Serology, gastroscopy, histology, and culture are used in the detection of H. Pylori [23].

In West Africa, a combination of diagnostic methods is largely used for diagnosis. In Ghana, up to the year 2012, the only methods used to diagnose H. Pylori were the rapid urease test and gastroscopy [24]. Gastroscopy and the rapid urease test have been shown in other studies to be mainly used in Ghana [25]. In Nigeria, H. Pylori diagnosis depends on gastroscopy, histology, serology, culture, stool antigen test and urea breath test. Patients presenting with dyspepsia in Northern Nigeria according to Olokoba et al have been diagnosed with H. Pylori using gastroscopy and histology [25]. The use of gastroscopy and histology for diagnosing H. Pylori has also been used in the South of Nigeria in a study by Ray-Offer and Obiorah [26]. In Nigeria, other studies conducted have used qPCR, culture from biopsy and urea breath test, stool PCR and stool antigen test for the diagnosis of H. Pylori [26]. Other authors have reported the use of gastroscopy, histology and culture in the diagnosis of H. Pylori infection [27]. Dyspeptic patients in public hospitals and in primary care settings in Cameroon have undergone serology to screen these patients of H. Pylori [28]. In Cameroon, the diagnosis of H. Pylori has also been carried out using histology and culture combined with the rapid urease test [29]. In Uganda, the diagnosis of H. Pylori has largely been carried out using gastroscopy, histology, serum antigen test, and rapid urease test [30]. Similarly, in Kenya, gastroscopy, histology, culture, rapid urease test and the serum antigen test have been used to diagnose H. Pylori. Several approaches in South Africa have been used to diagnose H. Pylori including gastroscopy, histology, culture, rapid urease test and PCR [31].

The European Society of Gastrointestinal Endoscopy has carried out a survey which has showed that African countries have a shortage of nonmedical and medical personnel [32]. Only 50% of African countries have non-academic and academic training centres for advanced and basic endoscopy [33]. Only the following countries which include Morocco, Nigeria, Burkina Faso, Ivory Coast and South Africa have National endoscopy societies. In Africa, the most frequent indications for upper GI endoscopy are infectious diseases and nonvariceal bleeding [32]. The diagnosis confirming H. Pylori is influenced by the cost of the test, availability, prevalence of infection and the use of over-the-counter antibiotics. After eradication treatment, many guidelines recommend noninvasive tests such as 13C urease breath test and serum antigen test in dyspeptic patients [34].

In several regions in Sub-Saharan Africa, there are no laboratories for H. Pylori serum antigen tests [35]. There have been obstacles in developing healthcare structures in Africa [35]. The Abuja Declaration in 2015 required investment of 15% of the annual budgets to go to the health sector, however, this goal was not achieved in any African country (WHO, 2015). The limited resources in the healthcare system are mainly due to a lack of funding, underpaid health worker staff, and unstable financial support [36]. When gastric biopsies are taken during gastroscopy, they are plated and rapidly cultured for H. Pylori antibiotic sensitivity and diagnosis. Alternatively, they are immediately frozen in 20% glycerol and shipped at -80 degrees centigrade on dry ice to the laboratory performing the culture [37]. An alternative to culture is next-generation sequencing to test for antibiotic sensitivity [37].

However, in Africa, resistance testing is limited by the lack of expertise and high cost [37]. Serological tests are not as accurate compared to these sensitivity tests but do not distinguish past from active H. Pylori infection [37].

Several guidelines for treatment of H. Pylori are available in developed high-income countries, due to the burden of H. Pylori and its association in the pathogenesis of gastroduodenal diseases. The treatment recommendations include guidelines from the American College of Gastroenterology (ACG), Toronto Consensus Conference and the Maastricht V/Florence Consensus [37]. These guidelines recommend a 14-day treatment as the first-line eradication treatment of H. Pylori. The combination of medications includes anti-secretory drugs and antibiotics. Local resistance patterns and penicillin allergy will direct the choice of antibiotics. In areas of low clarithromycin resistance (15% [42]. When another gastroscopy is carried out, second-line treatment is instituted. Appropriate treatment is first performed by carrying out standard antimicrobial susceptibility testing following culture. The need to carry out gastroscopy should dictate second-line treatment [42]. Due to the high H. Pylori resistance to clarithromycin, the rationale of this second-line treatment is to eliminate clarithromycin when gastroscopy is not possible or is not required. When gastroscopy is requested, more appropriate treatment may be instituted by performing cultures and antibiotic sensitivity testing [42]. The recommended second-line treatments include levofloxacin-triple therapy (levofloxacin + amoxicillin + PPI) or quadruple therapy (levofloxacin + amoxicillin + bismuth + PPI). When fluroquinolone resistance is <10% and there is a failure of standard triple therapy, levofloxacin—containing triple therapy is adequate treatment [43].

Culture and sensitivity testing should be used as a third-line treatment in those patients that fail quadruple regimens or clarithromycin-containing regimens [43]. The patient should be off the proton pump inhibitor, bismuth and off antibiotics before the H. Pylori test for at least two weeks [44]. After the completion of treatment, in order to avoid false-negative results, the H. Pylori test should be carried out four weeks after eradication treatment [44]. At gastroscopy, two biopsies are taken each from the body and antrum of the stomach as patients receiving PPIs have migration of H. Pylori from the antrum upwards towards the body of the stomach [45-47].

Increasing awareness among healthcare workers about the high prevalence of H. Pylori in Sub-Saharan Africa, training physicians and surgeons on making an early diagnosis, increasing endoscopy services and improving antibiotic prescribing are in the author’s opinion some of the most important ways to improve H. Pylori management in Sub-Saharan Africa [44-47].

For H. Pylori treatment there have been multiple antibiotic regimens which have been evaluated and there is no treatment regimen which guarantees a 100% cure rate. A high eradication rate has been found with only a few regimens. To guide treatment there is limited data on antibiotic resistance to H. Pylori. The ideal treatment regimen should take into consideration the cost, side effects, antibiotic allergies and route of administration. In many Sub-Saharan African countries, gastroscopy with biopsy will be ideal in cases of H. Pylori treatment failure. Due to the high-rate of antibiotic resistance in Sub-Saharan Africa, a consensus guideline is necessary to guide surgeons and physicians on the right antibiotic choice for eradication of H. Pylori.

Consent: It is not applicable

Ethical Approval: It is not applicable

Acknowledgements: The author acknowledges the support, willingness and expert management of the surgeons and physicians at Masaka Regional Referral Hospital, Uganda, East Africa for treating cases of H. Pylori appropriately.

Competing Interests: Author has declared that no competing interests exist.

1. Smith S, Fowora M, Pellicano R. Infections with Helicobacter pylori and challenges encountered in Africa. World J Gastroenterol. 2019; 25: 3183-395.
2. Sabbagh P, Javanian M, Koppolu V, Vasigala VR, Ebrahimpour S. Helicobacter pylori infection in children: an overview of diagnostic methods. Eur J Clin Microbiol Infect Dis. 2019; 38: 1035-1045.
3. Dolana B, Burkitt-Graya L, Shovelin S, Bourke B, Drumm B, Rowland M, et al.?The use of stool specimens reveals Helicobacter pylori strain diversity in a cohort of adolescents and their family members in a developed country. Int J Med Microbiol. 2018; 308: 247-2
4. Fock KM, Katelaris P, Sugano K, Ang TL, Hunt R, Talley NJ, et al. Second Asia-Pacific Conference. Second Asia-Pacific Consensus Guidelines for Helicobacter pylori infection. J Gastroenterol Hepatol. 2009; 24: 1587-1600.
5. Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017; 112: 212-239.
6. Malfertheiner P, Megraud F, Rokkas T, Gisbert JP, Liou JM, Schulz C, et al. European Helicobacter and Microbiota Study group. Management of Helicobacter pyloriinfection: the Maastricht VI/Florence consensus report. Gut. 2022; 2022-327745.
7. Fischbach W, Malfertheiner P. Helicobacter Pylori Infection. Dtsch Arztebl Int. 2018; 115: 429-436.
8. Makristathis A, Hirschl AM, Megraud F, Bessede E. Review: Diagnosis of Helicobacter pylori infection. Helicobacter. 2019; 1: e12641.
9. Talebi Bezmin Abadi A. Diagnosis of Helicobacter pyloriUsing Invasive and Noninvasive Approaches. J Pathog. 2018; 2018: 9064952.
10. Gold BD, Gilger MA, Czinn SJ. New Diagnostic Strategies for Detection of Helicobacter pylori Infection in Pediatric Patients. Gastroenterol Hepatol (NY). 2014; 10: 1-19.
11. Demiray-Gurbuz E, Y?lmaz O, Olivares AZ, Gonen C, Sar?oglu S, Soyturk M, et al. Rapid identification of Helicobacter pyloriand assessment of clarithromycin susceptibility from clinical specimens using FISH. J Pathol Clin Res. 2016; 3: 29-37.
12. Moosavian M, Tajbakhsh s, Samarbaf-Zadeh AR. Rapid detection of clarithromycin-resistant Helicobacter pyloriin patients with dyspepsia by fluorescent in situ hybridization (FISH) compared with the E-test. Ann Saudi Med. 2007; 2784-2788. 
13. Hassan EH, Gerges SS, El-Atrebi KA, El-Bassyouni HT. The role of H. pylori infection in gall bladder cancer: clinicopathological study. Tumour Biol. 2015; 36: 7093-7098.
14. Perets TT, Gingold-Belfer R, Leibovitzh H, Itskoviz D, Schmilovitz-Weiss H, Snir Y, et al. Optimization of (13) c-urea breath test threshold levels for the detection of helicobacter pylori infection in a national referral laboratory. J Clin Lab Anal.2019; 33: e22674.
15. Boltin D, Dotan I, Birkenfeld S. Improvement in the implementation of Helicobacter pylorimanagement guidelines among primary care physicians following a targeted educational intervention. Ann Gastroenterol. 2019; 32: 52-59.
16. Ferwana M, Abdulmajeed I, Alhajiahmed A, Madani W, Firwana B, Hasan R, et al. Accuracy of urea breath test in Helicobacter pylori infection: meta-analysis. World J Gastroenterol. 2015; 21: 1305-1314.
17. Ling D. Carbon-13 urea breath test for Helicobacter pylori infection in patients with uninvestigated ulcer-like dyspepsia: an evidence-based analysis. Ont Health Technol Assess Ser. 2013; 13: 1-30. 
18. Dolana B, Burkitt-Graya L, Shovelin S, Bourke B, Drumm B, Rowland M.?The use of stool specimens reveals Helicobacter pylori strain diversity in a cohort of adolescents and their family members in a developed country. Int J Med Microbiol. 2018; 308: 247-255.
19. Moubri M, Kalach N, Larras R, Berrah H, Mouffok F, Guechi Z, et al. Adapted first-line treatment of Helicobacter pyloriinfection in Algerian children. Ann Gastroenterol. 2019; 32: 60-66.
20. Alboraie M, Elhossary W, Aly OA, Abbas B, Abdelsalam L, Ghaith D, et al. Special interest group; Egyptian Association for Study of Gastrointestinal Diseases and Liver (EASGLD). Egyptian recommendations for management of Helicobacter pylori infection: 2018 report. Arab J Gastroenterol. 2019; 20: 175-179.
21. Abdurrazag N, Naser G, Muftah A, Huwiage, Aisha MA, Shahlol, Hind M. Khalifallah. Helicobacter pylori Infection in Healthy and Dyspeptic Adult populations Resident in Tripoli and Sabha of Libyan cities: A Seroepidemiologic Study. Journal of Pure and Applied Sciences.2019; 18.
22. Almehdawi?KA, Ali?RH. The prevalence of Helicobacter pylori infection in Benghazi, Libya. IOSR JDMS. 2016; 15: 73-77.
23. Altyar?IA, Abdalla?AM, Abdalwahab?SS, Abdalwahab?SS. The seroprevalence of Helicobacter pylori infection in Tripoli (Libya). Nat Sci. 2015; 13: 81-86.
24. Mansoura?KB, Keita?A, Zribi?M, Masmoudi?A, Zarrouk?S, Labbene?M, et al. Seroprevalence of Helicobacter pylori among Tunisian blood donors (outpatients), symptomatic patients and control subjects. Gastroenterol Clin Biol. 2010; 34: 75-82.
25. Darko?R, Yawson?AE, Osei?V, Owusu-ansah?J, Aluze-ele?S. Changing patterns of the prevalence of Helicobacter pylori among patients at a corporate hospital in Ghana. Ghana Med J. 2015; 49: 147-153.
26. Archampong?TN, Asmah?RH, Aidoo?EK, Wiredu?EK, Gyasi?RK, Adjei?DN. Helicobacter pylori cagA and vacA genes in dyspeptic Ghanaian patients. BMC Res Notes. 2017; 10: 231.
27. Archampong?TN, Asmah?RH, Wiredu?EK, Gyasi?RK, Nkrumah?KN, Rajakumar?K. Epidemiology of Helicobacter pylori infection in dyspeptic Ghanaian patients. Pan Afr Med J. 2015; 20: 178.
28. Tabiri?S, Alhassan?A, Anyomih?TK. Helicobacter pylori association with upper gastrointestinal pathologies in Northern Ghana. Ann Trop Med Public Health. 2018; 11: 48-51.
29. Olokoba?AB, Gashau?W, Bwala?S, Adamu?A, Salawu?FK. Helicobacter pylori infection in Nigerians with dyspepsia. Ghana Med J. 2013; 47: 79-81.
30. Ray-Offor?E, Obiorah?CC. Helicobacter pylori and precancerous lesions of the stomach in a Nigerian Metropolis: a cohort study. Niger J Clin Pract. 2018; 21: 375-379.
31. Ajayi?A, Jolaiya?TF, Smith?SI. Direct detection of Helicobacter pylori from biopsies of patients in Lagos, Nigeria using real-time PCR – a pilot study. BMC Res Notes. 2021; 14: 90.
32. Palamides?P, Jolaiya?T, Idowu?A, Loell?E, Onyekwere?C, Ugiagbe?R. Helicobacter pylori patient isolates from South Africa and Nigeria differ in virulence factor pathogenicity profile and associated gastric disease outcome. Sci Rep. 2020; 10: 11409.
33. Smith?SI, Fowora?MA, Lesi?OA, Agbebaku?E, Odeigah?P, Abdulkareem?FB, et al. Application of stool-PCR for the diagnosis of Helicobacter pylori from stool in Nigeria – a pilot study. Springer Plus. 2012; 1: 78.
34. Onyekwere?CA, Odiagah?JN, Igetei?R, Emanuel?AO, Ekere?F, Smith?S. Rabeprazole, clarithromycin, and amoxicillin Helicobacter pylori eradication therapy: report of an efficacy study. World J Gastroenterol. 2014; 20: 3615-3619.
35. Smith?SI, Fowora?MA, Otegbayo?JA, Abdulkareem?FB, Omonigbehin?EA, Adegboyega?A. Comparison of PCR with other diagnostic techniques for the detection of H. pylori infection in patients presenting with gastroduodenal symptoms in Nigeria. Int J Mol Epidemiol Genet. 2011; 2: 178-184.
36. Breurec?S, Michel?R, Seck?A, Brisse?S, Come?D, Dieye?FB, et al. Clinical relevance of cag A and vac A gene polymorphisms in Helicobacter pylori isolates from Senegalese patients. Clin Microbiol Infect. 2012; 18: 153-159.
37. Seck?A, Burucoa?C, Dia?D, Mbengue?M, Onambele?M, Raymond?J, et al.?Primary antibiotic resistance and associated mechanisms in Helicobacter pylori isolates from Senegalese patients. Ann Clin Microbiol Antimicrob. 2013; 12: 3.
38. Doh?K, Thiam?I, Halim?A, Takin?RCA, Woto-Gaye?G. Pathological overview of chronic gastritis in Senegal: results of upper gastrointestinal tract endoscopies. Med Sante Trop. 2017; 27: 439-442.
39. Mabeku?LBK, Epesse?MB, Fotsing?S, Kamgang?R, Tchidjo?M. Stool antigen testing, a reliable noninvasive method of assessment of Helicobacter pylori infection among patients with gastro-duodenal disorders in Cameroon. Dig Dis Sci. 2021; 66: 511-520.
40. Mabeku?LBK, Ngamga?MLN, Leundji?H. Potential risk factors and prevalence of Helicobacter pylori infection among adult patients with dyspepsia symptoms in Cameroon. BMC Infect Dis. 2018; 18: 278.
41. Aminde?JA, Dedino?GA, Ngwasiri?CA, Ombaku?KS, Makon?CAM, Aminde?LN. Helicobacter pylori infection among patients presenting with dyspepsia at a primary care setting in Cameroon: seroprevalence, five-year trend and predictors. BMC Infect Dis. 2019; 19: 30.
42. Agbor?NE, Esemu?SN, Ndip?LM, Tanih?NF, Smith?SI, Ndip?RN. Helicobacter pylori in patients with gastritis in West Cameroon: prevalence and risk factors for infection. BMC Res Notes. 2018; 11: 559.
43. Mabeku?LBK, Bille?BE, Zemnou?CT, Nguefack?LDT, Leundji?H. Broad spectrum resistance in Helicobacter pylori isolated from gastric biopsies of patients with dyspepsia in Cameroon and efflux-mediated multiresistance detection in MDR isolates. BMC Infect Dis. 2019; 19: 880.
44. Ankouane?F, Ngatcha?G, Tagni-Sartre?M, Biwole Sida?M, Ndjitoyap Ndam?EC. Helicobacter Pylori infection and peptic ulcer disease in children and adolescents from the age range of 6 to 18 years old in Yaounde (Cameroon). Health Sci Dis. 2015; 16: 1-6.
45. Obayo?S, Muzoora?C, Ocama?P, Cooney?MM, Wilson?T, Probert?CS. Upper gastrointestinal diseases in patients for endoscopy in South-Western Uganda. Afr Health Sci. 2015; 15: 959-966.
46. Oling?M, Odongo?J, Kituuka?O, Galukande?M. Prevalence of Helicobacter pylori in dyspeptic patients at a tertiary hospital in a low resource setting. BMC Res Notes. 2015; 8: 256.
47. Steurs?L. European aid and health system strengthening: an analysis of donor approaches in the DRC, Ethiopia, Uganda, Mozambique and the global fund. Glob Health Action. 2019; 12: 1.