US Gastroenterology & Hepatology Review, 2006;(1):52-54
Longer version of article from Reference Section:
There are very few conditions in medicine that can be treated as effectively as Helicobacter (H.) pylori infection. Many controlled treatment trials have an eradication rate in excess of 90%.1 Once a treatment has been successful, re-infection is rare and if the patient is found to have the bacteria at a later date, it is more likely to be a recrudescence rather than a re-infection. It is usually the exact same strain of bacteria that is found in patients who are thought to be re-infected.2 This bacterial infection is unusual, as it is gastroenterologists rather than microbiologists that dictate treatment.
Guideline Recommendations
The search for successful treatment has taken almost a decade. Initially, monotherapy was used, then dual therapy and, eventually, the successful treatment with triple therapy, i.e. three drugs twice daily for one week.3–5 Treatment of the infection has been the focus of worldwide guideline recommendations.6–8 The firstline therapy is a standard dosage of proton pump inhibitors (PPIs) twice daily with amoxicillin 1g twice daily and clarithromycin 500mg twice daily. There is some minor disagreement on the duration of treatment; the US guidelines recommend a 14-day course, whereas in Europe, a seven-day course is considered to be sufficient. A meta-analysis reveals a 12% advantage for a longer course treatment, but this is at added expense and greater risk of side effects.
Compliance
The major limitations to the success of treatment are both patient and physician compliance to guideline recommendations. The treatment is complex and it is known that individuals who have received third-level education achieve only a 50% compliance to a five-day course of antibiotics. Patient education is vital for successful treatment.They should be warned of possible side effects such as diarrhea and antibiotic sensitivity. Diarrhea is usually transient and self-limiting but, occasionally, cases of Clostridium difficile have been reported. Monilial infection can occur in females and prophylactic anti-fungal therapy may be beneficial. More recently, probiotics have been recommended to limit side effects.9 Giving a patient an explanatory leaflet and instruction on how to take therapy is helpful. Combination blister packs will also likely improve compliance. Combining the drugs into a single capsule will likely improve patient compliance.10 It is necessary to stress the importance of compliance, as failure to complete a course of therapy will normally result in the bacteria becoming resistant to clarithromycin, which prohibits the use of this antibiotic again.
Despite universal recommendation of triple therapy, physician compliance can be poor.11 Substitution of antibiotics is common and may result in the use of antibiotics that have no effect against the bacteria.There is no difference in the efficacy of the various PPIs in eradicating H. pylori, but they are superior to the H2 receptor antagonist, which cannot be recommended.12 The dose of antibiotic is important; 500mg clarithromycin is superior to 250mg, and amoxicillin should be prescribed 1g twice daily.
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