Helicobacter pylori (H pylori) infections remain an important cause of gastritis, ulcers, and adenocarcinoma of the stomach. One new approach in treatment has been the use of sequential therapy. More data is now available on the effectiveness of this approach and choice of antibiotics (Gastroenterology 2012; 143: 55-61 & editorial 10-12).
In the study, a 10-day sequential regimen (SR) was compared with a 5-day concomitant regimen (CR).
- CR group (n=90): esomeprazole 40 mg BID, amoxicillin 1 g BID, levofloxacin 500 mg BID, tinidazole 500 mg BID. Eradication rate (intention-to-treat): 92%
- SR group (n-90): esomeprazole 40 mg BID, amoxicillin 1 g BID for 5 days, then esomeprazole 40 mg BID, levofloxacin 500 mg BID, tinidazole 500 mg BID for 5 days. Eradication rate (intention-to-treat): 93%
- Both groups had good results in part due to low resistance rates
Useful advice on this study from the editorial:
- ‘We prefer concomitant therapy because it is not complex and it may retain its effectiveness at a slightly higher level of resistance compared with sequential therapy.” Authors prefer 4-drug non-bismuth-containing concomitant treatment.
- With bismuth therapy (eg. bismuth-metronidazole-tetracycline-PPI), authors prefer a 14 day course. 10-day treatment may be effective when metronidazole resistance is considered unlikely.
- “Clarithromycin should be abandoned as an empiric regimen” due to resistance in U.S.
- Fluoroquinolone resistance is increasing rapidly and “prior use virtually ensures resistance.” Suggested use of fluoroquinolone therapy among adults would be as a rescue therapy (failed 2 different therapies), using dosing regimen as noted in cited study, and in patient without history of prior fluoroquinolone use (&/or proof on susceptibility testing)
- -Gut 2010; 59: 1143-53. Changing treatment recommendations for Helicobacter pylori in the face of resistance.
- -Am J Gastroenterol 2007; 102: 1808-1825. American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection. Doxycycline can be used in place of tetracycline
- -Gastroenterol 2007; 133: 985. Review. Good article for resistant infections.
- -Gastroenterol 2005; 129:1414-19. Sequential Rx (amox + PPI x 5 days, then biaxin, tinidazole, PPI for 5 days) had 97% success.