Towards an Individualised Treatment of Helicobacter pylori Infection

Optimal treatment of H. pylori should produce cure rates of at least 90%, preferably 94% or greater per protocol. Initially, 14-day triple therapy was highly successful but clarithromycin resistance led to a fall in cure rates to 80% or less. Intelligent choice of empiric therapy requires knowledge of the local or regional patterns of drug resistance and monitoring the outcome of therapy to provide early warning of development of resistance.

We recommend the following general rules 1) Do not use legacy triple therapy consisting of a PPI, clarithromycin and amoxicillin unless it has been proven to be highly effective locally; 2) Do not reduce the doses of commonly used antibiotics unless it has been shown that lower doses reliably produce eradication rates of 90% or greater; 3) The duration of therapy should be 14 days unless a shorter duration has been shown locally to produce equally high treatment success; 4) Following treatment failure avoid reuse clarithromycin or fluoroquinolones as resistance had likely developed and cannot be overcome by increasing the dose or duration of therapy; and 5) Avoid clarithromycin and fluoroquinolones in first line therapy if either has been used in the past even for a different indication. We recommend using four drug combinations as first line (i.e., concomitant, hybrid, or bismuth-containing regimens). Second-line therapy should consist of antimicrobials that have not been used previously. Salvage therapy (i.e., after 2 or more failures) should be chosen on the basis of the results of antimicrobial susceptibility testing.

Keywords: MALT, mucosa-associated lymphoid tissue, ITP, immune thrombocytopenic purpura, PPI, proton pump inhibitor, H. pylori, Helicobacter pylori, ITT, intention to treat, bLf, bovine lactoferrin, S. boulardii, Saccharomyces boulardii.