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.