Helicobacter pylori –useful advice

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)
What about treatment in kids?
In pediatrics, guidelines for treatment have been recently updated (JPGN 2011; 53: 230-43). (Benjamin Gold, MD -one of my partners is one of the authors and was the lead author of the first guidelines published in 2000.)  NASPGHAN guidelines. PDF of powerpoint slides: H. pylori infection in children: ESPGHAN/ NASPGHAN guidelines … & pdf of text: Evidence-based guidelines from ESPGHAN and NASPGHAN for …
Recommendations for first line treatment are a triple-based therapy with PPI and two antibiotics (eg. amoxicillin and metronidazole).  Alternatives, include bismuth plus two antibiotics, or sequential therapy.  Use of clarithromycin is recommended only after susceptibility testing.

Additional references:

  • -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.

8 thoughts on “Helicobacter pylori –useful advice

  1. Pingback: What is Evidence-Based Medicine for Helicobacter Pylori? | gutsandgrowth

  2. Pingback: Understanding Resistance to Helicobacter pylori | gutsandgrowth

  3. Pingback: Gastritis –Not Due to Helicobacter pylori | gutsandgrowth

  4. Pingback: Helicobacter Pylori: Relationship to Cancer and Dubious Beneficial Claims | gutsandgrowth

  5. Pingback: Salvage Therapy and Standard Therapy for H pylori | gutsandgrowth

  6. Pingback: Quadruple Therapy for Helicobacter Pylori Favored in Toronto Guidelines | gutsandgrowth

  7. Pingback: ACG Guideline for Helicobacter Pylori | gutsandgrowth

  8. Pingback: Rifabutin-based Triple Therapy for H pylori | gutsandgrowth

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.