Treatment of ulcers can be improved and over-reliance on proton pump inhibitors reduced

EDITOR—Harris and Misiewicz in their review of managing Helicobacter pylori infection take a balanced view of the contentious issues surrounding treatment in patients without ulcers.1 But several inconsistencies are apparent in their approach to patients with ulcers, for whom solid evidence for treatment is available.

Harris and Misiewicz advocate only two attempts at eradication in patients with duodenal and gastric ulcers; failure of the second attempt is followed by maintenance treatment with antisecretory drugs. Although the 90% success rate for one course of eradication treatment is ideal, combined data from randomised controlled trials suggest that eradication rates of 73-87% are more usual.2 In everyday practice, rates of 64% or lower may be expected, depending on the regimen and interest of the clinician.3

After two courses of treatment, potentially one in eight patients may still be infected, and failure to persevere with eradication denies these patients a treatment that alters the natural history of the disease by preventing recurrence and haemorrhage of ulcers. Continuous antisecretory treatment is less convenient, less effective, and more costly; strategies must therefore be constructed to improve overall eradication rates.

In the light of this need to optimise success, Harris and Misiewicz's bias towards treatments based on using proton pump inhibitors and reluctance …