In a randomized, double-blind, multicenter trial, 67 patients were randomized to either metronidazole mg 3 times a day and tetracycline mg 4 times a day with either ranitidine mg 4 times a day or placebo. Eradication in the group receiving ranitidine was significantly enhanced with an eradication rate of A recent meta-analysis by Holtmann et al 69 suggests that eradication of H pylori with H 2 RAs in combination with antibiotics is similar to proton pump inhibitor combinations.
Thus, omeprazole has an advantage over ranitidine with respect to antibiotic resistance. This may be omeprazole's intrinsic antibacterial activity against H pylori , which ranitidine and other H 2 RAs do not possess.
Quadruple antibiotic therapies have consisted of traditional bismuth-based triple therapy with the addition of an antisecretory agent, either an H 2 RA or a proton pump inhibitor, to achieve close to complete eradication. These regimens have consistently achieved high eradication rates. In a randomized placebo-controlled trial, 71 consecutive patients with peptic ulcer disease and biopsy-proven H pylori infection were randomized to 7 days of triple therapy with or without omeprazole 20 mg twice a day or placebo.
Triple antibiotic therapy consisted of CBS mg 4 times a day , tetracycline hydrochloride mg 4 times a day , and metronidazole mg 3 times a day. Addition of omeprazole to this traditional triple therapy enhanced its efficacy. In another trial, 72 addition of either omeprazole or famotidine to triple antibiotic therapy was studied to see if the efficacy of triple antibiotic therapy could be improved.
This prospective, randomized study enrolled patients with symptoms of dyspepsia and confirmed H pylori infection. Patients received a day course of CBS chewable tablets mg 4 times a day, tetracycline mg 4 times a day , and metronidazole mg 4 times a day in addition to either omeprazole 20 mg twice daily or famotidine 40 mg at bedtime.
One-hundred twenty two of the Again, addition of a proton pump inhibitor resulted in enhanced eradication efficacy despite a greater prevalence of metronidazole-resistant isolates. Antibiotic resistance with regard to H pylori eradication has become a growing problem both here in the United States and in developing countries.
Recent studies have demonstrated that triple drug regimens that contain both metronidazole and clarithromycin are able to maintain their efficacy against H pylori despite metronidazole resistance. In a randomized multicenter trial 77 of patients with H pylori infection, 1 of the 3 following day regimens was administered: 1 omeprazole 20 mg , metronidazole mg , and clarithromycin mg twice daily; 2 omeprazole 20 mg , amoxicillin mg , and metronidazole mg twice daily; or 3 bismuth subcitrate mg , clarithromycin mg , and metronidazole mg twice a day.
None of the isolates were resistant to clarithromycin. Similar results were obtained in a randomized controlled trial 78 using omeprazole 20 mg , metronidazole mg , and clarithromycin mg twice daily for 1 week. Of the 64 patients enrolled, only 59 had successful culture and antibiotic sensitivity testing of their H pylori infection. The 3 patients who failed therapy all had isolates that were resistant to metronidazole, including the patient who had the isolate that was clarithromycin resistant.
Again, these 2 studies 77 , 78 demonstrate that, in those patients with only metronidazole-resistant isolates, triple therapy with metronidazole, clarithromycin, and omeprazole is still effective eradication therapy. Although clarithromycin is one of the newer agents used in the eradication of H pylori , resistant strains are emerging. Therefore, with greater use of clarithromycin in regimens to eradicate H pylori , there is a high likelihood that the prevalence of resistant strains will continue to increase.
This supports the view that clarithromycin-containing regimens should be avoided in those patients with prior exposure to the drug. For patients who have failed treatment with clarithromycin-containing regimens, effective alternative antibiotic combinations should be given. Choosing a single regimen from the myriad of regimens offered in the literature can be a bewildering experience; however, after careful analysis of the data, these can be narrowed to a select few.
Figure 1 outlines the algorithm we use for patients identified with a peptic ulcer and concurrent infection with H pylori. Table 1 lists the most effective regimens found in the literature. Based on the data reviewed, our first choice of treatment for eradication would be the metronidazole-omeprazole-clarithromycin regimen omeprazole [20 mg], clarithromycin [ mg], and metronidazole [ mg] twice a day for at least 7 to 10 days. In addition, preliminary data seem to indicate that metronidazole resistance does not appear to reduce the efficacy of this regimen, suggesting that it can still be used in areas where metronidazole resistance is frequent; however, studies to directly address this issue still need to be conducted.
Where eradication therapy becomes difficult is in those patients who fail initial treatment with metronidazole omeprazole clarithromycin. At this stage, we suggest that these patients receive the highly effective bismuth-based triple therapy bismuth-metronidazole-amoxicillin or bismuth-metronidazole-tetracycline plus a proton pump inhibitor for at least 2 weeks.
We feel patients with H pylori infection who develop recurrent ulcers, have symptoms or bleeding, and have failed initial H pylori eradication therapy would be more inclined to comply with treatment, especially if the clinician stresses the importance of completing therapy and its impact on long-term outcome. Subsequent eradication failures become more difficult to manage.
At this point, the clinician should attempt to culture the organism and obtain antibiotic sensitivities. This is not commonly done and requires a laboratory that specializes in H pylori antibiotic sensitivity testing. It is clear that eradication of H pylori is important in ulcer disease; however, the confusion comes with which regimen to choose. From our review of the literature on eradication, it has become clear that 7- to day regimens containing a proton pump inhibitor in combination with metronidazole and clarithromycin are highly efficacious and well tolerated.
Unfortunately, as more and more patients receive eradication therapy, antibiotic resistance will become a growing problem, especially as the prevalence of clarithromycin resistance increases. As a result, antibiotic sensitivity testing will play a greater role in the future of eradication therapy. Still, there are presently very effective regimens against H pylori ; however, the search for improved treatments requiring fewer pills and shorter courses continues.
Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy Continue. View Large Download. Most Effective Regimens for the Eradication of Helicobacter pylori. Soll AH Medical treatment of peptic ulcer disease: practice guidelines. N Engl J Med. J Clin Pathol. Inhibitory antimicrobial concentrations against Campylobacter pyloridis in gastric mucosa.
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High dose proton pump inhibitors plus amoxycillin for the treatment or retreatment of Helicobacter pylori infection. Abramowicz Med Clarithromycin and omeprazole for Helicobacter pylori. Med Lett. The flagella beat like arms to propel the bacteria around the stomach. Helicobacter pylori normally infect the stomachs of children where, in most cases, they stay forever. In developed countries like the UK, the H. In developing countries, it might also be spread in contaminated water , however, this is not proven.
Most infected people are blissfully unaware of these germs. For around one in five infected people, gastritis can, many years later, lead to one of several diseases including peptic ulcers , which are open sores in the lining of the stomach. These are the rare MALT lymphoma and a stomach cancer called gastric adenocarcinoma. Gastric adenocarcinoma is the fifth most common cause of death due to cancer in the world and around new cases are diagnosed in the UK each year.
Patients with ulcers or gastric problems are usually tested with the following three tests:. The infection may be found at the same time as a peptic ulcer or gastroduodenitis with a test called endoscopy. A single antibiotic would be prescribed to treat most bacterial infections but treating an H. It commonly involves two or three antibiotics , delivered with a drug called a proton pump inhibitor, which temporarily reduces acid secretion in the stomach.
The development of resistance to antibiotic treatments is becoming a major concern for many disease-causing bacteria and H. Since it was discovered by Marshall and Warren that H. In many countries including the UK, these have now become relatively rare conditions. The discovery that stomach cancers are caused by H. Nowadays, people diagnosed with H. If you are concerned about H.
He then underwent rigorous structured specialty training in gastroenterology and general internal medicine in the well respected South London training programme. His research was in the fields of pharmacogenetics, inflammatory Where available, treatment failure should prompt endoscopy and culture and susceptibility testing. Overall, higher doses and longer durations of treatment result in the best cure rates.
When multiple treatment regimens fail, salvage therapy regimens such as bismuth or furazolidone quadruple therapy a bismuth and tetracycline HCl 4 times a day along with a proton pump inhibitor twice a day, and either metronidazole or mg three times daily or furazolidone mg three times daily for 14 days can be used.
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