Treatment of Helicobacter pylori infection

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Wink A de Boer, internista,
Guido N J Tytgat, professorb

^aDepartment of Internal Medicine, Sint Anna Hospital, Postbus 10, 5340 BE Oss, Netherlands
^bDepartment of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands

Correspondence to: W A de Boer

The bacterium Helicobacter pylori can infect the stomach during childhood and cause lifelong chronic gastritis, which can lead to peptic ulcer disease. Curing H pylori infection cures ulcer disease.1^–5 And since reinfection in adults is extremely rare,6 adequate treatment permanently cures this former chronic recurrent, serious disease. If ulcers do not recur neither do ulcer perforation or bleeding; quality of life increases,7 sick leave decreases, and less money is spent on visiting the doctor and drugs.

Antibiotic resistance needs to be taken into account when designing treatment for H pylori infection.8 Over the past decade many different therapies were promoted and recommendations changed rapidly. Most doctors lost track, and a great variety of treatments is being used.9 In this article we will try to provide a basic framework on which treatment can be based.

Summary points

The therapeutic goal is to cure H pylori infection in all ulcer patients

Several equally effective regimens are available, but even the best fail in 5-20% of patients

Antibiotic resistance is usually induced after failure, and initial regimens should not compromise future therapeutic possibilities

Doctors should choose two complementary regimens, which if used consecutively come close to 100% cure

Treatment should start with a regimen based on clarithromycin with a back up regimen based on metronidazole unless resistance is above 15%, in which case the order should be reversed

Triple regimens which combine clarithromycin and metronidazole should not be used as there is no valid empirical back up regimen after failure

Methods

This article is based largely on our experience in treating H pyloriinfection. We base our recommendations on basic bacteriological principles and on a regularly updated in-house computer database that contains the results of all published therapeutic studies.