Evidence-based recommendations for successful Helicobacter pylori treatment

Abstract

An effective Helicobacter pylori therapy reliably provides high cure rates in infections with susceptible strains. It is possible to predict the efficacy of any regimen if one knows the prevalence of antibiotic resistance for a regimen or for a specific patient. We show how to predict the outcome for current regimens and discuss the factors that undermine different regimens (i.e., their Achilles heel). In general, in Western countries, clarithromycin-containing triple and sequential therapy should be considered obsolete as empiric therapies. Preferred regimens are 14-day concomitant or bismuth-containing quadruple therapy. We provide details of how to identify a regimen for a patient or region that will reliably cure 90% or more as well as those that will reliably fail.

Keywords::

• amoxicillin
• concomitant therapy
• furazolidone
• Helicobacter pylori
• levofloxacin
• metronidazole
• prediction model
• proton pump inhibitor
• resistance
• rifabutin
• sequential therapy
• susceptibility
• therapy

Financial & competing interests disclosure

The study was funded by the National Clinical Trial Center of National Taiwan University Hospital and the National Science Council, Executive Yuan, ROC, Taiwan (Grant Number: NSC 102-2325-B-002-074 and NSC 102-2325-B-002-084). DY Graham is supported in part by the Office of Research and Development Medical Research Service Department of Veterans Affairs, Public Health Service grants DK067366 and DK56338, which funds the Texas Medical Center Digestive Diseases Center. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the VA or NIH. DY Graham is also an unpaid consultant for Novartis in relation to vaccine development for treatment or prevention of Helicobacter pylori infection. DY Graham is also a paid consultant for RedHill Biopharma regarding novel H. pylori therapies and for Otsuka Pharmaceuticals regarding diagnostic breath testing. DY Graham has received royalties from Baylor College of Medicine patents covering materials related to 13C-urea breath test. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Helicobacter pylori is fundamentally no different from any other common infectious disease and cure rates of 95% or greater should be expected.

• Treatment failures are most often related to choice of an inferior regimen for that population (e.g., traditional triple therapy).

• Treatment failures using good regimens are primarily due to the presence of antibiotic resistance or poor compliance with the regimen.

• Optimized regimens provide similar results in all regions and countries with similar patterns of resistance.

• One can predict and even calculate outcomes prospectively provided one knows the local pattern of resistance either by susceptibility testing or by assessing the results of therapy.

• It is possible to identify which therapies are likely to be successful and those who will likely fail based on antibiotic usage in the country, region or patient.

• No treatment trial should be done without susceptibility testing as studies without susceptibility data are largely uninterpretable.

• It is unethical to randomize patients to a known inferior therapy and such trials should neither be done nor published.

• Meta-analyses of therapies failing to achieve acceptable cure rates should neither be published nor done.