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Optimal therapy for Helicobacter pylori infections

Nature Reviews Gastroenterology & Hepatology volume 8, pages 79–88 (2011)Cite this article

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Abstract

Although Helicobacter pylori infection is both a common and a serious bacterial infection, antimicrobial therapies have rarely been optimized, are prescribed empirically, and provide inferior results compared with antimicrobial therapies for other common infectious diseases. The effectiveness of many of the frequently recommended H. pylori infection treatment regimens has been increasingly compromised by antimicrobial resistance. Regional data on the susceptibility of strains of H. pylori to available antimicrobials are sorely needed. Noninvasive molecular methods are possible to assess clarithromycin susceptibility in isolates obtained from stool specimens. As a general rule, clinicians should prescribe therapeutic regimens that have a ≥90% or, preferably, ≥95% eradication rate locally. If no available regimen can achieve a ≥90% eradication rate, clinicians should use the most effective regimen(s) available locally. Eradication of infection should always be confirmed after treatment in order to provide feedback regarding local effectiveness and an early warning of increasing resistance. In most regions of the world, four-drug treatment regimens, including a PPI plus three antimicrobials (clarithromycin, metronidazole/tinidazole and amoxicillin), or a PPI plus a bismuth plus tetracycline and metronidazole provide the best results. Standard triple therapy (a PPI, amoxicillin and clarithromycin) should now be avoided owing to increasing resistance to this treatment.

Key Points

  • New treatment regimens for Helicobacter pylori infection should be optimized to achieve an eradication rate of ≥95% before their use in clinical practice

  • A patient's allergies and the local availability of drugs should be considered when selecting a treatment

  • If there is no available therapy with an eradication rate ≥90%, the most locally effective therapy available should be employed

  • Treatment should involve high drug doses (for example, 500 mg of clarithromycin, metronidazole or tetracycline) for 14 days unless lower doses and a shorter duration of therapy are equally effective locally

  • H. pylori eradication should be confirmed after treatment, and, if second-line therapy is required, clarithromycin or a fluoroquinolone should not be reused

  • Salvage therapy (after multiple treatment failures) should be chosen on the basis of susceptibility testing whenever possible

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Figure 1: Detection of clarithromycin-susceptible and clarithromycin-resistant Helicobacter pylori in paraffin-embedded gastric tissue sections by whole-cell hybridization with fluorescence-labeled oligonucleotides.
Figure 2: Percentage of treatment success for triple therapy in studies of populations in southern Europe and other geographic areas according to intention-to-treat analysis.
Figure 3: The theoretical effect of increasing clarithromycin resistance on the success of treatment of Helicobacter pylori infection with triple therapy (a PPI, clarithromycin and amoxicillin) for 7 or 14 days.
Figure 4: Average annual recurrence of Helicobacter pylori infection after successful eradication in developing countries.82,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115
Figure 5: Incidence of recurrence or reinfection of Helicobacter pylori in the first year after successful eradication, and incidence of cumulative reinfection or recurrence of H. pylori over all years of follow-up in developing countries.83,84,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123

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Acknowledgements

This material is based upon work supported in part by the Office of Research and Development Medical Research Service Department of Veterans Affairs. Dr. Graham is supported in part by Public Health Service grant DK56338, which funds the Texas Medical Center Digestive Diseases Center. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the VA or NIH. C. P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, 2002 Holcombe Boulevard, Houston, 77030, TX, USA

    Emiko Rimbara & David Y. Graham

  2. University of North Texas Health Science Center, School of Public Health, 3500 Camp Bowie Boulevard, CBH 320, Fort Worth, 76107, TX, USA

    Lori A. Fischbach

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  1. Emiko Rimbara
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E. Rimbara, L. A. Fischbach and D. Y. Graham contributed equally to researching data for the article, discussing content, and writing and reviewing/editing of the manuscript before submission.

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Correspondence to David Y. Graham.

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Competing interests

D. Y. Graham is a Consultant for Otsuka Pharmaceuticals, has previously been a Consultant for Meretek amd is an unpaid Consultant for Novartis. E. Rimbara and L. A. Fischbach declare no competing interests.

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Rimbara, E., Fischbach, L. & Graham, D. Optimal therapy for Helicobacter pylori infections. Nat Rev Gastroenterol Hepatol 8, 79–88 (2011). https://doi.org/10.1038/nrgastro.2010.210

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