Clinical Review

Treatment of Helicobacter pylori infection

BMJ 2008; 337 doi: (Published 15 September 2008) Cite this as: BMJ 2008;337:a1454
  1. L Fuccio, research fellow1,
  2. L Laterza, research fellow1,
  3. R M Zagari, assistant professor1,
  4. V Cennamo, attending physician1,
  5. D Grilli, assistant professor2,
  6. Franco Bazzoli, professor1
  1. 1Department of Internal Medicine and Gastroenterology, University of Bologna, 40138, Bologna, Italy
  2. 2Department of Economics, University of South Florida, FL 33620, USA
  1. Correspondence to: F Bazzoli franco.bazzoli{at}
  • Accepted 6 June 2008

Summary points

  • The prevalence of H pylori varies widely and is about 50% in international population studies

  • Triple and quadruple multidrug regimens are standard treatment

  • Resistance to clarithromycin and metronidazole and lack of adherence to treatment are the main predictors of treatment failure

  • The choice of the most effective regimen should be based on the prevalence of antibiotic resistance, especially resistance to clarithromycin and metronidazole

  • Individualised treatment based on antimicrobial susceptibility has a limited role in H pylori eradication strategies

  • The overall risk of reinfection is estimated at 3.4% per patient year in developed countries, rising to 8.7% in developing countries

Helicobacter pylori is one of the most common human infections, and about half of the world’s population carries this organism. Since its discovery in 1984, H pylori has been recognised as a major cause of several upper gastrointestinal diseases.1 2 As with other chronic infectious diseases, several antibiotics must be given simultaneously and sometimes repeated courses of different combinations of antibiotics are needed to eradicate H pylori. Eradicating H pylori is still a challenge, however, because of the rapidly increasing prevalence of multidrug resistant strains worldwide. In recent years, several randomised controlled trials and meta-analyses have proposed new regimens and treatment strategies for H pylori infection. This review will discuss the available treatment strategies for H pylori infection and help identify the most effective one.

How common is H pylori infection?

The prevalence of H pylori varies widely, with more than 80% of adults being infected in Japan and South America compared with around 40% in the United Kingdom and 20% in Scandinavia.3 Epidemiological evidence suggests that many people acquire the infection in childhood—social deprivation, household crowding, and number of siblings are important risk factors. The prevalence of infection increases with age, although this may be largely a cohort effect. Poorer socioeconomic conditions 60 …

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