Efficacy of a multistep strategy for Helicobacter pylori eradication.
BACKGROUND
Helicobacter pylori eradication therapies do not achieve 100% success rates. Antibiotic resistant strains are among the major causes of failure. Current recommendations concerning the management of treatment failures are not fully clear.


OBJECTIVE
To evaluate the efficacy of a multi-step therapeutic strategy in a large group of infected patients.


METHODS
A total of 2606 H. pylori-positive patients were administered tinidazole, clarithromycin and a proton pump inhibitor for 1 week. Patients with continuing infection were then given a second 1-week course of amoxycillin, clarithromycin and ranitidine bismuth citrate. Patients still infected after the second course underwent upper gastrointestinal endoscopy with H. pylori culture, and then received a 1-week quadruple proton pump inhibitor-bismuth based scheme established on H. pylori antibiotic sensitivity.


RESULTS
After the first step, eradication was achieved in 2063 out of 2413 patients [86% per protocol analysis (PP); 79% intention-to-treat analysis (ITT)]. First-step failures (350 out of 2413; 14.5% PP) showed second-step eradication rates of 82% (271 out of 329 patients, PP; 77% ITT). The specific quadruple therapy for second-step failures (58 out of 329, 18% PP) achieved 77% (30 out of 39 patients, PP) or 52% (ITT) success. This algorithm led to overall eradication rates of 99% (PP) or 91% (ITT).


CONCLUSIONS
This multi-step strategy succeeded in a high percentage of H. pylori infected patients. Given the lack of precise guidelines on treatment failures, assessing H. pylori sensitivity to antibiotics only after failure of the second treatment could be suggested in clinical practice.
Gasbarrini
A
A
Medical Pathology, Catholic University of Rome, Italy. angiologia@rm.unicatt.it
Ojetti
V
V
Armuzzi
A
A
Branca
G
G
Canducci
F
F
Torre
E S
ES
Candelli
M
M
Pastorelli
A
A
Anti
M
M
Fedeli
G
G
Fadda
G
G
Pola
P
P
Gasbarrini
G
G
D000465:Algorithms; D000658:Amoxicillin / Q000008:administration & dosage / Q000627:therapeutic use*; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D000897:Anti-Ulcer Agents / Q000008:administration & dosage / Q000627:therapeutic use; D001729:Bismuth / Q000008:administration & dosage / Q000627:therapeutic use; D017291:Clarithromycin / Q000008:administration & dosage / Q000627:therapeutic use*; D004352:Drug Resistance, Microbial; D004359:Drug Therapy, Combination / Q000008:administration & dosage / Q000627:therapeutic use; D005260:Female; D016481:Helicobacter Infections / Q000188:drug therapy*; D016480:Helicobacter pylori; D006801:Humans; D008297:Male; D008875:Middle Aged; D010406:Penicillins / Q000008:administration & dosage / Q000627:therapeutic use*; D011899:Ranitidine / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000627:therapeutic use; D014011:Tinidazole / Q000627:therapeutic use*; D017211:Treatment Failure
D000900:Anti-Bacterial Agents; D000897:Anti-Ulcer Agents; D010406:Penicillins; D014011:Tinidazole; C073340:ranitidine bismuth citrate; D000658:Amoxicillin; D011899:Ranitidine; D017291:Clarithromycin; D001729:Bismuth