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Review Article |

Treatment of Helicobacter pylori Infection FREE

Julio A. Salcedo, MD; Firas Al-Kawas, MD
[+] Author Affiliations

From the Department of Gastroenterology, Georgetown University Medical Center, Washington, DC.


Arch Intern Med. 1998;158(8):842-851. doi:10.1001/archinte.158.8.842.
Text Size: A A A
Published online

Since acceptance of the association between Helicobacter pylori and peptic ulcer disease, eradication of H pylori has become the standard of care in the treatment of peptic ulcer disease. Unfortunately, eradication therapy is no easy task, especially when one is faced with a myriad of drug combinations with varying degrees of efficacy and tolerability. The following is a review of the literature regarding the drugs and drug combinations used to eradicate H pylori and their effectiveness both as single agents and in combination.

Figures in this Article

It is widely accepted that most peptic ulcers are associated with Helicobacter pylori infection and that the eradication of the organism leads to enhanced ulcer healing and reduces the chance of ulcer recurrence.1Helicobacter pylori can be eradicated with the use of antibiotics; however, more than 1 agent has to be used in combination with either a proton pump inhibitor or bismuth to achieve eradication rates of 90% or greater. In addition, many of these regimens require a significant number of pills in frequent doses and must be taken for at least 7 days, making compliance difficult. Antibiotic resistance is an emerging problem and has to be taken into account when choosing a regimen, especially after initial eradication therapy has failed. This review will present current information concerning the efficacy and mode of action of the various antibiotics and drug combinations used to eradicate H pylori. Eradication is defined as a negative result from a repeated test for the detection of H pylori (ie, histologic, rapid urease, or breath test) at least 4 weeks after completing therapy. Antibiotic resistance and its effect on eradication efficacy will also be discussed with recommendations for proper therapeutic choice.

Single Agents
Amoxicillin

Helicobacter pylori is very sensitive to amoxicillin both in vivo and in vitro.2 Like other penicillins, amoxicillin works by inhibition of bacterial cell wall synthesis, leading to cell death. Amoxicillin has topical intraluminal activity at the level of the gastric mucosa, as well as systemic activity. Unlike ampicillin, amoxicillin is actively secreted into the gastric juices from the blood stream.3,4 Despite being secreted into the gastric juice and mucosa during oral therapy, amoxicillin by itself achieves less than a 20% eradication rate of H pylori.5,6 More than 2 g a day of amoxicillin does not increase its eradication rate of H pylori when used as a single agent.7 However, when it is given in combination with omeprazole, the concentration of amoxicillin in the gastric juice and its eradication efficacy increase significantly.8 It is hypothesized that this eradication enhancement comes about by omeprazole decreasing gastric secretions, thus increasing the intragastric concentration of amoxicillin to more than the minimal inhibitory concentration (MIC) of H pylori, as well as decreasing the MIC of amoxicillin by increasing the gastric pH.8 The advantage of using amoxicillin is that H pylori does not develop resistance to it, and, therefore, it can be used again in another antibiotic regimen.7

Tetracycline

Tetracycline has been used primarily in combination with other antibiotics for the eradication of H pylori. It is stable at a low pH and, like amoxicillin, has activity against H pylori as a topical agent, achieving concentrations in the gastric juice and mucosa much greater than the published MIC of H pylori. Used alone, tetracycline is unable to eradicate H pylori infection; however, H pylori resistance has not been reported. This regimen cannot be used in children or pregnant women, because it causes permanent staining of developing teeth.

Metronidazole

Metronidazole is a nitroimidazole used primarily for the treatment of anaerobic and parasitic infections. In the past decade, it has become a mainstay in the treatment of H pylori infection. In Western countries where metronidazole use is very low, more than 70% of H pylori isolates are sensitive to metronidazole9; however, H pylori eradication is rarely achieved when it is given as a single agent. In fact, in developing countries where metronidazole use is more common, there have been reports that more than 80% of H pylori isolates are metronidazole resistant.1012 Therefore, metronidazole is always given in combination with 1 or more antibiotics. Metronidazole resistance is attributed to a mutation resulting in a strain of H pylori with defective nitroreductase.13 Metronidazole is stable at a low pH and is actively secreted into the gastric juice. Active secretion of metronidazole is diminished when it is given with a proton pump inhibitor.8 It has a half-life of 8 to 12 hours. The most common adverse effects of metronidazole are a metallic taste in the mouth, nausea, and epigastric discomfort. Metronidazole has been reported to produce a disulfiramlike reaction when taken in combination with alcohol.

Bismuth Salts

Bismuth salts have been used for medicinal purposes for more than 200 years. Bismuth acts topically and as an antimicrobial agent against H pylori by disrupting the organism's cell wall. In addition, bismuth may also interfere with adhesion of H pylori to the gastric epithelium, as well as inhibiting the organism's urease, phospholipase, and proteolytic activity.2 Frequent doses of bismuth are required since adequate antibacterial gastric mucosal concentrations only last for 2 hours. Bismuth is only available in the United States as bismuth subsalicylate (BSS; Pepto-Bismol [an upset stomach remedy]). Colloidal bismuth subcitrate (CBS; De-Nol [an upset stomach remedy]) is the other form of bismuth that is available in the rest of the world. According to Marshall and colleagues,7,14 BSS is less effective against H pylori than CBS when given as a single agent, having an approximately 10% eradication rate, compared with a 40% eradication rate with CBS. In combination with 1 or more antibiotics, the mean eradication rate rises dramatically, with rates greater than 80% when given in combination with 2 antibiotics.15

Clarithromycin

Clarithromycin is a new generation macrolide antibiotic, which is acid stable and well absorbed from the gut. It has a longer half-life than erythromycin—3 to 4 hours for clarithromycin, compared with 1 to 2 hours for erythromycin. Its antibacterial activity is similar to that of erythromycin, but it is clearly more effective against H pylori. In addition, it is broken down in the liver to a hydroxylated compound that is also active against H pylori. Clarithromycin is unique in that as a single agent it by far has the best activity against H pylori, achieving between 40% to 60% eradication rates.16 Clarithromycin achieves the best eradication rate when given frequently and in larger doses.17 Unfortunately, as with metronidazole, when clarithromycin is given as monotherapy, resistance can develop.17 Clarithromycin can alter the taste sensation, producing a bitter metallic taste that results in noncompliance.

Azithromycin

Azithromycin is one of the newer orally administered macrolide antibiotics. Like clarithromycin, it too is acid stable. Azithromycin is well absorbed from the gastrointestinal tract and extensively distributed in tissues and reaches concentrations much greater than the MICs of common infectious pathogens. The elimination half-life of azithromycin increases with time after the dose, and with each subsequent dose the elimination half-life increases. After an initial oral dose of 1000 mg, followed by 500 mg/d for 5 days, the elimination half-life has been reported to be 57 hours.18 Azithromycin has excellent in vitro activity against H pylori.19 It is not effective as a single agent because of acquired resistance.20 However, when it is used in combination with other antibiotics, improved eradication rates are achieved.21

Ranitidine Bismuth

Ranitidine bismuth citrate (RBC) is a bismuth compound with histamine2-receptor–antagonist (H2RA) activity formed by the reaction of ranitidine with bismuth citrate and is precipitated as an amorphous compound.22 The agent has been developed for the treatment of patients with duodenal ulcer with or without infection with H pylori. The RBC is freely soluble in water, whereas an equimolar admixture of ranitidine and bismuth citrate forms an almost insoluble suspension.23 Even at a pH of 2, the solubility of RBC is still 2-fold better than the admixture. The RBC has antipepsin activity and enhanced antibacterial activity against H pylori that is not observed with the admixture of ranitidine and bismuth citrate. It is hypothesized that the greater solubility of RBC is what confers these added properties. When given alone, RBC has been shown to suppress H pylori.24 This effect is enhanced by taking RBC with food rather than on an empty stomach.24 As a single agent, however, RBC achieves a 20% eradication rate.25 A combination of RBC with clarithromycin has resulted in eradication rates in the range of 72% to 80%, comparable to those of triple antibiotic therapy.26

Dual Antibiotic Therapy
Bismuth Plus 1 Antibiotic

The eradication rate of CBS and amoxicillin is dependent on both the total daily dose of amoxicillin and how frequently it is given.27 The eradication rate after 28 days of this dual therapy increased from 33% in one study28 to 70% in another,29 when the dose of amoxicillin was increased from 500 mg twice a day to 500 mg 4 times a day. The eradication rates of CBS plus metronidazole have been variable with no consistent trend to suggest that more frequent or larger doses of metronidazole are required to improve eradication efficacy.27 Results with BSS and another antibiotic have been disappointing, requiring several weeks of therapy to achieve eradication rates slightly greater than 50%.30 A meta-analysis by Chiba et al15 demonstrates that the mean eradication rate for dual therapy composed of bismuth plus another antibiotic, primarily amoxicillin or metronidazole, is approximately 50%. Because of its variable results, as well as low rate of eradication, bismuth plus a single antibiotic is not considered adequate therapy for eradication.

Amoxicillin Plus a Proton Pump Inhibitor

Axon31 reviewed several studies examining the eradication of H pylori using either omeprazole or lansoprazole with amoxicillin and found the results to be variable. Early studies,32,33 primarily from Germany, reported eradication rates of 80% to 85% with omeprazole (20 mg twice a day) and at least 1 g of amoxicillin twice a day. However, these results have not been replicated in similar trials. A meta-analysis by Chiba et al34 showed that, independent of the dose given or duration of therapy of omeprazole and amoxicillin, the overall eradication rate using this dual therapy is approximately 60%. Some trials have suggested that giving a total daily dose of 40 mg or more of omeprazole in divided doses or larger doses of amoxicillin, usually more than 2 g/d for at least 2 weeks, enhance the efficacy of the amoxicillin-omeprazole combination.27 This was not the case in a recent study by Malaty et al,35 where only a 34.9% eradication rate was observed in H pylori–infected patients who were treated with a 14-day course of a large dose of a proton pump inhibitor (either omeprazole [40 mg twice daily] or lansoprazole [60 mg twice daily]) and amoxicillin [750 mg twice daily]). Omeprazole pretreatment prior to the addition of amoxicillin has been demonstrated to reduce the efficacy of this combination significantly.36 Because the efficacy data of this combination are so variable, amoxicillin combined with a proton pump inhibitor is no longer considered an adequate first choice for eradication.

Clarithromycin Plus a Proton Pump Inhibitor

Recently, the Food and Drug Administration has approved the marketing of clarithromycin and omeprazole for concurrent use in the treatment of duodenal ulcers associated with H pylori.37 In the study by Logan et al,38 2 weeks of clarithromycin (500 mg 3 times a day) plus omeprazole (40 mg/d) followed by 2 additional weeks of omeprazole achieved an eradication rate of 83%. In 2 US studies39,40 using the same regimen, the eradication rates were lower, 74% and 64%. Chiba41 demonstrated that reducing the dose of clarithromycin to 250 mg twice a day in this regimen lowers the eradication rate (62.1%). Studies27,42 that used a lower dose of omeprazole, usually less than 40 mg/d, also had lower eradication rates. Comparable results have been described with lansoprazole and clarithromycin. An eradication rate of 72.4% was attained with lansoprazole (30 mg twice a day) and clarithromycin (400 mg twice a day) administered for 2 weeks; however, when a lower dose of lansoprazole (30 mg/d) was used with the same dose of clarithromycin, the eradication rate declined to 50%.43 The effectiveness of this dual regimen is dependent on the dose of the proton pump inhibitor and clarithromycin. Although frequent adverse effects have been reported with this dual therapy (approximately 45%), in general, this regimen has been well tolerated with most of the adverse reactions being mild.44 Taste perversion is the most common complaint, and this is likely related to the clarithromycin. In the US studies mentioned above, 3.5% of the patients enrolled discontinued the regimen because of adverse events. Both omeprazole and lansoprazole directly inhibit the growth of H pylori in vitro; therefore, using larger doses may possibly result in better eradication rates.45 In addition, a beneficial pharmacokinetic drug interaction exists between omeprazole and clarithromycin where the area under the curve for both drugs' clearance is increased when the 2 drugs are given concomitantly.46 This also results in higher concentrations of clarithromycin in the gastric mucosa and gastric mucus.4 These pharmacokinetic interactions probably enhance the antisecretory effects of omeprazole as well as the antibacterial effect of clarithromycin, explaining in part why this combination is more effective when given together.

Clarithromycin Plus RBC

This combination was recently approved by the Food and Drug Administration. As mentioned earlier, the combination of RBC with clarithromycin has been shown to be effective in eradicating H pylori infection. In a multicenter randomized, double-blind, placebo-controlled trial26 of 205 patients with an active duodenal ulcer, the group treated with RBC (400 mg twice a day) for 4 weeks and clarithromycin (500 mg 3 times a day) during the first 2 weeks of therapy was associated with an 82% eradication rate at 4 weeks. Only 36% of the group that received clarithromycin alone cleared their infection. These findings are consistent with previous studies47,48 using similar doses and duration of treatment. The number of patients that left the study because of adverse reactions was similar between the treatment and placebo groups.

Triple Antibiotic Therapy
Bismuth Triple Therapies

The early regimens used to eradicate H pylori used bismuth as the cornerstone of triple therapy. The most effective treatments consisted of bismuth plus 2 antibiotics—usually metronidazole and tetracycline or metronidazole and amoxicillin. Pooled data27 have demonstrated that those bismuth-based regimens using tetracycline instead of amoxicillin in combination with metronidazole are more efficacious with a mean eradication rate of 87%, compared with 72%. Recently, Tefera et al49 conducted a study using a triple therapy consisting of bismuth subcitrate (150 mg 4 times a day), oxytetracycline (500 mg 4 times a day), and metronidazole (400 mg 3 times a day) for 10 days. This regimen resulted in an eradication rate of 91%. In the arm of the study that used metronidazole placebo, the eradication rate dropped to 9%. This implies that the efficacy of this regimen is highly dependent on metronidazole. Another recent trial50 demonstrated a similar eradication rate with a comparable regimen of bismuth, metronidazole, and tetracycline. Fifty-five infected patients received a 14-day course of tetracycline (250 mg), metronidazole (250 mg), and CBS (120 mg), 4 times a day. This regimen yielded a 96.3% eradication rate, which is consistent with previous studies. Of the 55 patients, 8 had H pylori isolates that were metronidazole resistant. Seven of these 8 patients were tested for treatment efficacy, and all but 1 had cleared their infection using this triple antibiotic regimen. The implication is that this regimen is still quite effective for patients with metronidazole-resistant strains of H pylori, and this has been shown to be the case in several other trials.51 Another trial52 used a large dose of the same antibiotic combination (bismuth subcitrate [120 mg], tetracycline [500 mg], and metronidazole [400 mg] 4 times a day) in 55 patients with duodenal ulcer and H pylori infection. Treatment was for only a week. An eradication rate of 83.7% was achieved; however, compliance was fair to poor in 45% of the patients enrolled. The most common adverse effects reported were nausea, dizziness, malaise, metallic taste, and anorexia. Six of the 55 patients enrolled could not complete the study because of the adverse effects of this combination. Therefore, despite an acceptable rate of eradication, the higher doses of tetracycline and metronidazole in this regimen make it difficult to tolerate.

Because of metronidazole-resistant strains of H pylori, investigators have substituted either clarithromycin or azithromycin for metronidazole in the standard bismuth-based triple therapies in an effort to overcome this problem. Al-Assi et al53 studied the combination of clarithromycin (500 mg 3 times a day), tetracycline (500 mg 4 times a day), and BSS (2 tablets [151 mg per tablet] 4 times a day) in 30 infected patients. The combination was administered for 14 days. At 4 weeks, 93% of the patients were cured of their infection, including 3 patients who had previously failed therapy containing metronidazole. This combination is very effective against H pylori and may be an alternative treatment in those patients who are infected with metronidazole-resistant isolates.

As mentioned, azithromycin is a new macrolide antibiotic that is very active against H pylori and achieves excellent tissue penetration with a long half-life. In one study,54 30 patients with H pylori infection were treated with 1 of 2 regimens: 2 tablets of BSS (each tablet contained 151 mg of bismuth) 4 times a day, tetracycline hydrochloride (500 mg 4 times a day), and either azithromycin (250 mg twice a day in one group [18 patients] or 250 mg 3 times a day in the other [12 patients]) for 2 weeks. The overall eradication rate in both groups was 50%. The group receiving azithromycin 3 times a day (750 mg/d) achieved a significantly higher eradication rate of 83%; however, two thirds of this group also experienced frequent and troublesome adverse effects, which included diarrhea (most common), stomatitis, dysgeusia, and facial and tongue swelling. Despite a comparable eradication rate to other effective bismuth-based triple therapies, this triple therapy is limited because its efficacy relies on high doses of azithromycin, which produce much too high a rate of adverse effects to make this regimen practical.

Another trial55 studied the combination of azithromycin, metronidazole, and bismuth. Fifty-six patients infected with H pylori received bismuth subcitrate (120 mg 4 times a day for 14 days) along with azithromycin (500 mg daily for the first 3 days) and metronidazole (250 mg 4 times a day for the first 7 days). The eradication rate for this regimen was 58.9%. Only 3 patients in this group experienced an adverse event; however, all were able to complete treatment. Although the adverse-effect profile improved by decreasing the dose and frequency of azithromycin administration, the eradication rate was significantly lowered, making this regimen impractical.

Most studies regarding bismuth-based triple therapy have been conducted using CBS, but more recent trials suggest that BSS can achieve similar eradication rates in the same combinations.27

To date, the bismuth-based triple therapies are the most effective and least costly treatments for the eradication of H pylori, because they have high cure rates even in those patients infected with metronidazole-resistant strains. Unfortunately, compliance is poor with these regimens because of the large number of tablets and frequent adverse effects. Adverse effects are seen in approximately 30% of patients and include diarrhea, dizziness, headache, nausea, paraesthesia, and a disulfiramlike reaction when metronidazole and alcohol are taken concurrently.56 Compliance is the single most important factor that affects the eradication rate of this regimen. Graham et al57 demonstrated that for those patients who took less than 60% of bismuth-based triple therapy the eradication rate dropped from 96% to 69%. Still, the search for therapies that are more effective than bismuth-based regimens is ongoing.

Proton Pump Inhibitors as a Component of Triple Therapy

In an attempt to find more tolerable triple drug regimens, proton pump inhibitors have been studied in combination with 2 other antibiotics. The most studied has been omeprazole in combination with either metronidazole and amoxicillin or metronidazole and clarithromycin. Both regimens possess eradication rates greater than 85%.34 In a recent randomized controlled trial58 of 183 patients with an active duodenal ulcer and histologically proven H pylori gastric infection, omeprazole (20 mg/d for 4 weeks) plus amoxicillin (1 g 3 times a day) and metronidazole (250 mg 4 times a day) during the second and third week was associated with a 90% eradication rate. Another trial59 treating 22 patients using the same combination (omeprazole [40 mg/d], amoxicillin [500 mg 3 times a day], and metronidazole [250 mg 4 times a day]) for 2 weeks achieved a similar eradication rate of 86.4%. More recently, in a randomized trial,60 31 patients were treated with a 1-week course of this omeprazole-antibiotic combination. After receiving omeprazole (20 mg twice a day), amoxicillin (1 g twice a day), and metronidazole (500 mg twice a day), only 79% of the infected patients had cleared their infection 4 to 6 weeks after completing treatment. This implies that perhaps it is necessary to treat patients with this regimen longer to achieve a higher eradication rate.

A smaller study61 evaluated the efficacy of triple therapy using metronidazole, omeprazole, and clarithromycin. Thirty-three patients with documented H pylori infection received omeprazole (20 mg twice a day), clarithromycin (250 mg twice a day), and metronidazole (500 mg twice a day) for 2 weeks. Helicobacter pylori was eradicated in 88% of the patients. Moreover, 90% (18/20) of those patients who had failed prior eradication therapy achieved a cure with this regimen. A similar eradication rate (93.3%) was achieved in another trial41 using the same 2-week regimen of metronidazole, omeprazole, and clarithromycin in 30 patients. This regimen has also been shown to retain its efficacy when given for only a week. In an international multicenter, double-blind randomized placebo-controlled trial,62 105 of 111 patients receiving a 7-day course of omeprazole (20 mg twice a day), metronidazole (400 mg twice a day), and clarithromycin (250 mg twice a day) cleared their infection (95%) as proven by carbon 13–urea breath test 4 weeks after the completion of treatment.

In this same study,62 the combination of omeprazole (20 mg twice a day), clarithromycin (500 mg twice a day), and amoxicillin (1000 mg twice a day) for 7 days was also shown to be effective in 106 of 110 patients, with a 96% eradication rate. However, when the dose of clarithromycin was decreased to 250 mg twice a day, the eradication rate decreased to 84%, suggesting that the efficacy of this combination is dependent on the dose of clarithromycin. Additionally, the efficacy of this therapy is also dependent on the length of time that it is given. In a small randomized trial,63 patients received omeprazole (20 mg twice daily), clarithromycin (500 mg twice daily), and amoxicillin (1 g twice daily) for 7, 10, or 14 days. The rate of cure was greater in the group who received 10 or more days of treatment (eradication rate of 88% after 10 days and 100% after 14 days).

Lansoprazole, another proton pump inhibitor, has been shown to be just as effective as omeprazole in triple antibiotic therapy. In a multicenter trial64 conducted in the United Kingdom and Ireland, patients with either duodenal ulcer or gastritis and H pylori infection were randomized to 1 of 4 1-week regimens: lansoprazole (30 mg twice a day) plus clarithromycin (250 mg twice a day) with either amoxicillin (1 g) or metronidazole (400 mg) twice daily or amoxicillin (1 g) plus metronidazole (400 mg twice a day) with either lansoprazole (30 mg) or omeprazole (20 mg) twice a day. The combination of lansoprazole, amoxicillin, and clarithromycin and lansoprazole, clarithromycin, and metronidazole had eradication rates of 89.7% and 90.4%, respectively. The eradication rates of the lansoprazole, amoxicillin, and metronidazole and omeprazole, amoxicillin, and metronidazole therapies were 72.5% and 81.7%, respectively. Therefore, lansoprazole when used in combination with clarithromycin and either amoxicillin or metronidazole for 1 week is still as effective as omeprazole in the same combination, retaining a 90% eradication rate.

Histamine2-Receptor Antagonists in Triple Antibiotic Therapy

Histamine2-receptor antagonists (H2RAs) have been used in combination with 2 antibiotics for the eradication of H pylori with good success. Hentschel et al,65 in a randomized, double-blind trial, achieved an 89% eradication rate using metronidazole, amoxicillin, and ranitidine for 12 days, followed by 30 additional days of ranitidine. A similar rate of eradication (86%) was achieved in patients with peptic ulcer disease with a 10-day regimen of ranitidine (600 mg before bedtime [which was continued for a total of 6 weeks to ensure ulcer healing]), amoxicillin (750 mg 3 times a day), and clarithromycin (500 mg 3 times a day).66

The addition of ranitidine enhances the eradication rate of dual antibiotic therapy. In a randomized, double-blind, multicenter trial,67 156 patients were randomized to either metronidazole (250 mg 3 times a day) and tetracycline (500 mg 4 times a day) with either ranitidine (150 mg 4 times a day) or placebo. Eradication in the group receiving ranitidine was significantly enhanced with an eradication rate of 66.7%, compared with 36% in those receiving placebo. The minimal dose of ranitidine required in combination with dual antibiotics to achieve maximal eradication efficacy has been shown to be at least 600 mg/d.68

A recent meta-analysis by Holtmann et al69 suggests that eradication of H pylori with H2RAs in combination with antibiotics is similar to proton pump inhibitor combinations. In a study by Powell et al,70 2 weeks of ranitidine (300 mg/d) combined with metronidazole (400 mg 3 times a day) and amoxicillin (500 mg 3 times a day), compared with the same antibiotic regimen using omeprazole (40 mg/d) instead of ranitidine, was similar in efficacy in eradicating metronidazole-sensitive H pylori strains (96% vs 98%). However, in those patients with metronidazole-resistant isolates, the omeprazole-containing regimen was superior to the ranitidine combination (76% vs 50%). Thus, omeprazole has an advantage over ranitidine with respect to antibiotic resistance. This may be omeprazole's intrinsic antibacterial activity against H pylori, which ranitidine and other H2RAs do not possess.

Quadruple Antibiotic Therapy

Quadruple antibiotic therapies have consisted of traditional bismuth-based triple therapy with the addition of an antisecretory agent, either an H2RA or a proton pump inhibitor, to achieve close to complete eradication. These regimens have consistently achieved high eradication rates. In a randomized placebo-controlled trial,71 108 consecutive patients with peptic ulcer disease and biopsy-proven H pylori infection were randomized to 7 days of triple therapy with or without omeprazole (20 mg twice a day) or placebo. Triple antibiotic therapy consisted of CBS (120 mg 4 times a day), tetracycline hydrochloride (500 mg 4 times a day), and metronidazole (500 mg 3 times a day). Ninety-eight percent of patients (53/54 patients) treated with omeprazole had their infection eradicated, compared with 83.3% (45/54 patients) who did not receive omeprazole (P=.02). Addition of omeprazole to this traditional triple therapy enhanced its efficacy.

In another trial,72 addition of either omeprazole or famotidine to triple antibiotic therapy was studied to see if the efficacy of triple antibiotic therapy could be improved. This prospective, randomized study enrolled patients with symptoms of dyspepsia and confirmed H pylori infection. Patients received a 12-day course of CBS chewable tablets (108 mg) 4 times a day, tetracycline (250 mg 4 times a day), and metronidazole (200 mg 4 times a day) in addition to either omeprazole (20 mg twice daily) or famotidine (40 mg at bedtime). One-hundred twenty two of the 125 (97.6%) patients who completed the study achieved eradication whereas only 110 of 124 (89%) of those patients who were receiving famotidine had cleared their infection. The pretreatment prevalence of metronidazole-resistant strains was greater in the group receiving omeprazole (24%), compared with the group receiving famotidine (21%). Again, addition of a proton pump inhibitor resulted in enhanced eradication efficacy despite a greater prevalence of metronidazole-resistant isolates.

Antibiotic resistance with regard to H pylori eradication has become a growing problem both here in the United States and in developing countries. In some countries, the prevalence of metronidazole-resistant strains approaches 70% and is associated with prior exposure to metronidazole.73 Some of the most effective regimens against H pylori include metronidazole; however, there have been reports74,75 that their efficacy is diminished when isolates are metronidazole resistant. Several research groups76 have demonstrated a 30% to 60% reduction in the eradication rate of standard bismuth-based triple therapy when given to individuals with metronidazole-resistant strains compared with patients with metronidazole-sensitive organisms. Yet others have found no reduction in eradication rates using standard bismuth-based triple therapy in areas where the prevalence of metronidazole-resistant strains are between 20% and 40%.57 This conflict has prompted researchers to find regimens that can be used reliably against metronidazole-resistant strains. Recent studies have demonstrated that triple drug regimens that contain both metronidazole and clarithromycin are able to maintain their efficacy against H pylori despite metronidazole resistance. In a randomized multicenter trial77 of 230 patients with H pylori infection, 1 of the 3 following 10-day regimens was administered: (1) omeprazole (20 mg), metronidazole (400 mg), and clarithromycin (250 mg) twice daily; (2) omeprazole (20 mg), amoxicillin (750 mg), and metronidazole (400 mg) twice daily; or (3) bismuth subcitrate (240 mg), clarithromycin (250 mg), and metronidazole (400 mg) twice a day. The eradication rates for the metronidazole-omeprazole-amoxicillin, metronidazole-omeprazole-clarithromycin, and bismuth subcitrate-clarithromycin-metronidazole groups were 95%, 91%, and 95%, respectively, with no statistical difference among the groups. Metronidazole resistance was found in 29% of the patients. None of the isolates were resistant to clarithromycin. When those patients with the metronidazole-resistant isolates were analyzed separately, eradication rate for the metronidazole-omeprazole-amoxicillin group was 77% (17/22 patients), compared with 100% (23/23 patients) for the bismuth subcitrate-clarithromycin-metronidazole group and 94% (17/18 patients) for the metronidazole-omeprazole-clarithromycin group.

Similar results were obtained in a randomized controlled trial78 using omeprazole (20 mg), metronidazole (400 mg), and clarithromycin (250 mg) twice daily for 1 week. Of the 64 patients enrolled, only 59 had successful culture and antibiotic sensitivity testing of their H pylori infection. Twenty-five patients (42%) were found to have H pylori isolates that were metronidazole resistant, including 1 patient whose isolate was also clarithromycin resistant. Still, 61 (95%) of 64 patients achieved successful eradication of their infection. The 3 patients who failed therapy all had isolates that were resistant to metronidazole, including the patient who had the isolate that was clarithromycin resistant. Again, these 2 studies77,78 demonstrate that, in those patients with only metronidazole-resistant isolates, triple therapy with metronidazole, clarithromycin, and omeprazole is still effective eradication therapy.

Although clarithromycin is one of the newer agents used in the eradication of H pylori, resistant strains are emerging. Compared with metronidazole resistance, clarithromycin resistance is of relatively low prevalence here in the United States (approximately 4%); however, in Belgium and France, where macrolide use is high, the prevalence is close to 10%.76,79 Unfortunately, a study by Cayla80 has shown that exposure to clarithromycin without successful eradication of H pylori results in a clarithromycin-resistant strain in approximately two thirds of eradication failures. Therefore, with greater use of clarithromycin in regimens to eradicate H pylori, there is a high likelihood that the prevalence of resistant strains will continue to increase. This supports the view that clarithromycin-containing regimens should be avoided in those patients with prior exposure to the drug. For patients who have failed treatment with clarithromycin-containing regimens, effective alternative antibiotic combinations should be given.

Choosing a single regimen from the myriad of regimens offered in the literature can be a bewildering experience; however, after careful analysis of the data, these can be narrowed to a select few. Figure 1 outlines the algorithm we use for patients identified with a peptic ulcer and concurrent infection with H pylori. Table 1 lists the most effective regimens found in the literature. Based on the data reviewed, our first choice of treatment for eradication would be the metronidazole-omeprazole-clarithromycin regimen (omeprazole [20 mg], clarithromycin [500 mg], and metronidazole [500 mg] twice a day) for at least 7 to 10 days. As mentioned earlier, several studies41,62,77,78 have demonstrated that this regimen carries an eradication rate of 90% or more and is well tolerated by most patients, resulting in good patient compliance. In addition, preliminary data seem to indicate that metronidazole resistance does not appear to reduce the efficacy of this regimen, suggesting that it can still be used in areas where metronidazole resistance is frequent; however, studies to directly address this issue still need to be conducted.

Place holder to copy figure label and caption

Recommended algorithm for the eradication of Helicobacter pylori. EGD indicates esophagogastroduodenoscopy; CLO, campylobacterlike organism; H2RA, histamine2-receptor antagonist; PPI, proton pump inhibitor; and NSAID, nonsteroidal anti-inflammatory drug.

Graphic Jump Location
Table Graphic Jump LocationMost Effective Regimens for the Eradication of Helicobacter pylori

Where eradication therapy becomes difficult is in those patients who fail initial treatment with metronidazole omeprazole clarithromycin. At this stage, we suggest that these patients receive the highly effective bismuth-based triple therapy (bismuth-metronidazole-amoxicillin or bismuth-metronidazole-tetracycline) plus a proton pump inhibitor for at least 2 weeks. These regimens consistently achieve eradication rates greater than 95%; however, compliance is diminished because of the number of pills required and the associated adverse effects. We feel patients with H pylori infection who develop recurrent ulcers, have symptoms or bleeding, and have failed initial H pylori eradication therapy would be more inclined to comply with treatment, especially if the clinician stresses the importance of completing therapy and its impact on long-term outcome.

Subsequent eradication failures become more difficult to manage. At this point, the clinician should attempt to culture the organism and obtain antibiotic sensitivities. This is not commonly done and requires a laboratory that specializes in H pylori antibiotic sensitivity testing. Once this information is in hand, an appropriate regimen with at least an 80% eradication rate can be tried.

It is clear that eradication of H pylori is important in ulcer disease; however, the confusion comes with which regimen to choose. From our review of the literature on eradication, it has become clear that 7- to 14-day regimens containing a proton pump inhibitor in combination with metronidazole and clarithromycin are highly efficacious and well tolerated. Unfortunately, as more and more patients receive eradication therapy, antibiotic resistance will become a growing problem, especially as the prevalence of clarithromycin resistance increases. As a result, antibiotic sensitivity testing will play a greater role in the future of eradication therapy. Still, there are presently very effective regimens against H pylori; however, the search for improved treatments requiring fewer pills and shorter courses continues.

Accepted for publication September 11, 1997.

Reprints: Firas Al-Kawas, MD, Department of Gastroenterology, Georgetown University Medical Center, 3800 Reservoir Rd, NW, Room M2122, 2nd Floor/Main Building, Washington, DC 20007.

Soll  AH Medical treatment of peptic ulcer disease: practice guidelines. JAMA. 1996;275622- 629
Link to Article
Walsh  JHPeterson  WL The treatment of Helicobacterpylori infection in the management of peptic ulcer disease. N Engl J Med. 1995;333984- 991
Link to Article
van Zanten  SJOGoldie  JHollingsworth  JSilletti  CRichardson  HHunt  RH Secretion of intravenously administered antibiotics in gastric juice: implications for management of HelicobacterpyloriJ Clin Pathol. 1992;45225- 227
Link to Article
McNulty  CADent  JCFord  GA  et al.  Inhibitory antimicrobial concentrations against Campylobacter pyloridis in gastric mucosa. J Antimicrob Chemother. 1988;22729- 738
Link to Article
Oderda  GVaira  DHolton  J  et al.  Amoxycillin plus tinidazole for Campylobacter pylori gastritis in children: assessment by serum IgG antibody, pepsinogen I, and gastrin levels. Lancet. 1989;1690- 692
Link to Article
Rauws  EAJLangenberg  WHouthoff  HJ  et al.  Campylobacter pyloridis– associated chronic active antral gastritis: a prospective study of its prevalence and the effects of antibacterial and antiulcer treatment. Gastroenterology. 1988;94229- 238
Marshall  BJ Treatment strategies for Helicobacterpylori infection. Gastroenterol Clin North Am. 1993;22183- 198
Goddard  AFMohamed  JJBarrett  DA  et al.  Effect of omeprazole on the distribution of metronidazole, amoxicillin, and clarithromycin in human gastric juice. Gastroenterology. 1996;111358- 367
Link to Article
Goodwin  CSMarshall  BJBlincow  ED  et al.  Prevention of nitroimidazole resistance in Campylobacter pylori by coadministration of colloidal bismuth subcitrate: clinical and in vitro studies. J Clin Pathol. 1988;41207- 210
Link to Article
Bell  GDPowell  KUBurridge  SM  et al.  Short report: omeprazole plus antibiotic combinations for the eradication of metronidazole-resistant Helicobacter pyloriAliment Pharmacol Ther. 1992;6751- 758
Link to Article
Glupczynski  YBurette  Ade Koster  E  et al.  Metronidazole resistance in Helicobacter pylori [letter]. Lancet. 1990;335976- 977
Link to Article
European Study Group on Antibiotic Susceptibility of Helicobacter pylori, Results of a multicenter European survey in 1991 of metronidazole resistance in Helicobacter pyloriEur J Clin Microbiol Infect Dis. 1992;11777- 781
Link to Article
Cederbrant  GKahlmeter  GLjungh  A Proposed mechanism for metronidazole resistance in Helicobacter pyloriJ Antimicrob Chemother. 1992;29115- 120
Link to Article
Marshall  BJGoodwin  CSWarren  JR  et al.  A prospective double-blind trial of duodenal ulcer relapse after eradication of Campylobacter pyloriLancet. 1988;21437- 1442
Link to Article
Chiba  NRao  BVRademaker  JWHunt  RH Meta-analysis of the efficacy of antibiotic therapy in eradicating HelicobacterpyloriAm J Gastroenterol. 1992;871716- 1727
Neri  MSusi  DBovani  I  et al.  Omeprazole, bismuth, and clarithromycin: a new approach to the treatment of H pylori–related gastritis [abstract]. Gastroenterology. 1992;102A134Taken From: Aliment Pharmacol Ther. 1994;8:469-471
Peterson  WLGraham  DLMarshall  B  et al.  Clarithromycin as monotherapy for eradication of Helicobacter pylori: a randomized, double-blind trial. Am J Gastroenterol. 1993;881860- 1864
Foulds  GShepard  RMJohnson  RB The pharmacokinetics of azithromycin in human serum and tissues. J Antimicrob Chemother. 1990;25 ((suppl A)) 73- 82
Link to Article
Hardy  DJHanson  CWHensey  DM  et al.  Susceptibility of Campylobacter pylori to macrolides and fluoroquinolones. J Antimicrob Chemother. 1988;22631- 636
Link to Article
Glupczynski  YBurette  A Failure of azythromycin to eradicate Campylobacter pylori from the stomach because of acquired resistance during treatment [letter]. Am J Gastroenterol. 1990;8598- 99
Bertoni  GRomano  SNigrisoli  E  et al.  Triple therapy with azithromycin, omeprazole, and amoxicillin is highly effective in the eradication of Helicobacter pylori: a controlled trial versus omeprazole plus amoxicillin. Am J Gastroenterol. 1996;91258- 263
Prewett  EJNwokolo  CUHudson  M  et al.  The effect of GR122311X, a bismuth compound with H2-antagonist activity, on 24-hour intragastric acidity. Aliment Pharmacol Ther. 1991;5481- 490
Link to Article
McColm  AAMcLaren  AKlinkert  G  et al.  Ranitidine bismuth citrate: a novel antiulcer agent with different physicochemical characteristics and improved biological activity to a bismuth citrate-ranitidine admixture. Aliment Pharmacol Ther. 1996;10241- 250
Link to Article
Webb  DDCiociola  AAPerschy  TB  et al.  Effect of administration of ranitidine bismuth citrate with food on the suppression and eradication of Helicobacter pylori in infected volunteers. Am J Gastroenterol. 1995;901273- 1277
Bardhan  KDDekkers  CPMLam  SK  et al.  GR122311X (ranitidine bismuth citrate), a new drug for the treatment of duodenal ulcer. Aliment Pharmacol Ther. 1995;9497- 506
Link to Article
Peterson  WLCiociola  AASykes  DL  et al.  Ranitidine bismuth citrate plus clarithromycin is effective for healing duodenal ulcer, eradicating H pylori, and reducing ulcer recurrence. Aliment Pharmacol Ther. 1996;10251- 261
Link to Article
Dixon  JS Helicobacter pylori eradication: unravelling the facts. Scand J Gastroenterol. 1995;30 ((suppl 212)) 48- 62
Link to Article
Morgando  ATodros  LBoero  M  et al.  Therapy of Helicobacter pylori infection: clinical trials with double and triple pharmacological association. Ital J Gastroenterol. 1991;23 ((suppl 2)) 112
Susi  DBovani  INeri  MCuccurullo  F The eradication of Helicobacter pylori depends on the depth of mucosal invasion: an electronmicroscopical study. Ital J Gastroenterol. 1991;23 ((suppl 2)) 67- 68
Mannes  GABayerdorffer  EHochter  W  et al.  Decreased relapse rate after antibacterial treatment of Helicobacterpylori–associated duodenal ulcers: Munich Duodenal Ulcer Trial. Eur J Gastroenterol Hepatol. 1993;5145- 153
Link to Article
Axon  A The role of omeprazole and antibiotic combinations in the eradication of Helicobacter pyloriScand J Gastroenterol. 1994;29 ((suppl 205)) 31- 37
Link to Article
Bayerdorffer  EMannes  GASommer  A  et al.  Long-term follow up after eradication of Helicobacter pylori with a combination of omeprazole and amoxycillin. Scand J Gastroenterol. 1993;28 ((suppl 196)) 19- 25
Link to Article
Mannes  GABayerdorffer  EHochter  W  et al.  An increasing dose of omeprazole combined with amoxycillin increases the eradication of Helicobacter pylori [abstract]. Gastroenterology. 1993;104A140
Chiba  NWilkinson  JMHunt  RH Clarithromycin (C) or amoxicillin (A) dual and triple therapies in H pylori (Hp) eradication: a meta-analysis [abstract]. Gut. 1995;37 ((suppl 2)) 31
Link to Article
Malaty  HEl-Zimaity  HMTGenta  RM  et al.  High dose proton pump inhibitors plus amoxycillin for the treatment or retreatment of Helicobacter pylori infection. Aliment Pharmacol Ther. 1996;1001- 1004
Labenz  JLeverkus  FBōrsch  G Omeprazole plus amoxycillin for cure of H. pylori infection: factors influencing the treatment success. Scand J Gastroenterol. 1994;291070- 1075
Link to Article
Abramowicz  Med Clarithromycin and omeprazole for Helicobacter pyloriMed Lett. 1996;3851- 52
Logan  RPHBardhan  KDCelestin  LR Eradication of Helicobacter pylori and prevention of recurrence of duodenal ulcer: a randomized, double-blind, multicenter trial of omeprazole with or without clarithromycin. Aliment Pharmacol Ther. 1995;9417- 424
Link to Article
Not Available, U.S. Study M93067 [package insert].  North Chicago, Ill Abbott Laboratories
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Chiba  N Omeprazole and clarithromycin with and without metronidazole for the eradication of Helicobacter pyloriAm J Gastroenterol. 1996;912139- 2143
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Markham  AMcTavish  D Clarithromycin and omeprazole: as Helicobacter pylori eradication therapy in patients with H pylori–associated gastric disorders. Drugs. 1996;51161- 178
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Iwahi  TSatoh  HNakao  M  et al.  Lansoprazole, a novel benzimidazole proton pump inhibitor, and its related compounds have selective activity against Helicobacter pyloriAntimicrob Agents Chemother. 1991;35490- 496
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Gustavason  LEKaiser  JFEdmonds  AL  et al.  Evaluation of the pharmacokinetic drug interactions between clarithromycin and omeprazole. Antimicrob Agents Chemother. 1995;392078- 2083
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Wyeth  JWPounder  REDeKoster  E  et al.  GR122311X (ranitidine bismuth citrate) with antibiotics for the eradication of Helicobacter pylori [abstract]. Gastroenterology. 1994;106A212
Bardhan  KDDallaire  CEisold  HDuggan  AE The treatment of duodenal ulcer with GR122311X (ranitidine bismuth citrate) and clarithromycin [abstract]. Gut. 1995;37 ((suppl 1)) A5
Tefera  SBerstad  ABang  CJ  et al.  Bismuth-based combination therapy for Helicobacter pylori–associated peptic ulcer disease (metronidazole for eradication, ranitidine for pain). Am J Gastroenterol. 1996;91935- 941
Thijs  JCvanZwet  AAMoolenaar  W  et al.  Triple therapy vs amoxicillin plus omeprazole for treatment of Helicobacter pylori infection: a multicenter, prospective, randomized, controlled study of efficacy and side effects. Am J Gastroenterol. 1996;9193- 100
Graham  DYde Boer  WATytgat  GNJ Choosing the best anti–Helicobacter pylori therapy: effect of antimicrobial resistance. Am J Gastroenterol. 1996;911072- 1076
Sung  JJYChung  SCSLing  TKW  et al.  Dual therapy v triple therapy for Helicobacter pylori-associated duodenal ulcers. Dig Dis Sci. 1996;41453- 457
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Al-Assi  MTRamirez  FCLew  GM  et al.  Clarithromycin, tetracycline, and bismuth: a new nonmetronidazole therapy for Helicobacter pylori infection. Am J Gastroenterol. 1994;891203- 1205
Al-Assi  MTGenta  RMKarttunen  TJ Azithromycin triple therapy for H pylori infection: azithromycin, tetracycline, bismuth. Am J Gastroenterol. 1996;90403- 405
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Hunt  RH Eradication of Helicobacter pylori infection. Am J Med. 1996;100 ((suppl 5A)) 42S- 50S
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Graham  DYLew  GMMalaty  HM  et al.  Factors influencing the eradication of Helicobacter pylori with triple therapy. Gastroenterology. 1992;102493- 496
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Peramico  OZanetti  MVInnerhofer  M Omeprazole-based dual and triple therapy for the eradication of H. pylori infection in peptic ulcer disease: a randomized trial [abstract]. Gastroenterology. 1996;110A229
Yousfi  MMEl-Zimaity  HMTAl-Assi  MT  et al.  Metronidazole, omeprazole, and clarithromycin: an effective combination therapy for Helicobacter pylori infection. Aliment Pharmacol Ther. 1995;9209- 212
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Lind  TVeldhuyzen  Not Availablevan Zanten  SJOV  et al.  The MACH1 study: optimal one week treatment for H pylori defined? pylori infection in peptic ulcer disease: a randomized trial [abstract]. Gut. 1995;37 ((suppl 1)) A15
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Misiewicz  JJHarris  AWBardham  KDLevi  SLangworthy  H One week low-dose triple therapy for eradication of H. pylori: a large mulitcentre, randomised trial [abstract]. Gut. 1996;38 ((suppl 1)) A1
Link to Article
Hentschel  EBrandstätter  GDragosics  B  et al.  Effect of ranitidine and amoxicillin plus metronidazole on the eradication of Helicobacter pylori and the recurrence of duodenal ulcer. N Engl J Med. 1993;328308- 312
Link to Article
Al-assi  MTGenta  RMKarttunen  TJGraham  DY Clarithromycin-amoxicillin therapy for Helicobacter pylori infection. Aliment Pharmacol Ther. 1994;8453- 456
Link to Article
Massarrat  SIhm  PKoch  HK  et al.  The efficacy of two classic antibiotics, tetracycline and metronidazole, alone or with ranitidine on duodenal ulcer healing and eradication of H pylori [abstract]. Gastroenterology. 1996;110A188
Lamouliatte  HRuszniewski  PFléjou  JF  et al.  Effect of 3 doses of ranitidine (300, 600, 1200 mg/day) combined with two antibiotics in the eradication of Helicobacter pylori [abstract]. Gastroenterology. 1996;110A170
Holtmann  GLayer  PGoebell  H Proton pump inhibitors or histamine2-receptor antagonists for Helicobacterpylori eradication: a meta-analysis. Lancet. 1996;347763
Link to Article
Powell  KUBell  GDBowden  A  et al.  Helicobacter pylori eradication therapy: a comparison between either omeprazole or ranitidine in combination with amoxycillin plus metronidazole [abstract]. Gut. 1995;35 ((suppl 5)) S16
deBoer  WDriessen  WJansz  ATytgat  G Effect of acid suppression on efficacy of treatment for Helicobacter pylori infection. Lancet. 1995;345817- 820
Link to Article
Borody  TJAndrews  PFracchia  G  et al.  Omeprazole enhances efficacy of triple therapy in eradicating Helicobacter pyloriGut. 1995;37477- 481
Link to Article
Gutiérrez  OAngel  ASegura  AMGenta  RMGraham  DY Effectiveness of triple therapy for Helicobacter pylori in countries where metronidazole resistance is common [abstract]. Gastroenterology. 1996;110A126
Noach  LALangenberg  WLBertola  MA  et al.  Impact of metronidazole resistance on the eradication of Helicobacter pyloriScand J Infect Dis. 1994;26321- 327
Link to Article
Goddard  AFLogan  RPH Antimicrobial resistance and Helicobacter pyloriJ Antimicrob Chemother. 1996;37639- 643
Link to Article
Rautelin  HSeppala  KRenkonen  OV  et al.  Role of metronidazole resistance in therapy of Helicobacter pylori infections. Antimicrob Agents Chemother. 1992;36163- 166
Link to Article
Lerang  FMoum  BHaug  JB  et al.  Highly effective twice a day triple therapies for Helicobacter pylori infection and peptic ulcer disease: metronidazole resistance is of only minor importance [abstract]. Gastroenterology. 1996;110A173
Peitz  UNusch  ATillenburg  B  et al.  Frequent metronidazole resistance without significant impact on the high cure rate of Helicobacter pylori (HP) infection by triple therapy with omeprazole (OME), metronidazole (MET), and clarithromycin (CLA) [abstract]. Gastroenterology. 1996;110A226
Olson  CEdmonds  A Primary susceptibility of H pylori to clarithromycin compared to metronidazole in patients with duodenal ulcers associated with H pylori infection [abstract]. Gut. 1995;37 ((suppl 2)) A814
Cayla  RZerbib  FTalbi  P  et al.  Pre- and post-treatment clarithromycin resistance of Helicobacter pylori strains: a key factor of treatment failure [abstract]. Gut. 1995;37 ((suppl 1)) A217

Figures

Place holder to copy figure label and caption

Recommended algorithm for the eradication of Helicobacter pylori. EGD indicates esophagogastroduodenoscopy; CLO, campylobacterlike organism; H2RA, histamine2-receptor antagonist; PPI, proton pump inhibitor; and NSAID, nonsteroidal anti-inflammatory drug.

Graphic Jump Location

Tables

Table Graphic Jump LocationMost Effective Regimens for the Eradication of Helicobacter pylori

References

Soll  AH Medical treatment of peptic ulcer disease: practice guidelines. JAMA. 1996;275622- 629
Link to Article
Walsh  JHPeterson  WL The treatment of Helicobacterpylori infection in the management of peptic ulcer disease. N Engl J Med. 1995;333984- 991
Link to Article
van Zanten  SJOGoldie  JHollingsworth  JSilletti  CRichardson  HHunt  RH Secretion of intravenously administered antibiotics in gastric juice: implications for management of HelicobacterpyloriJ Clin Pathol. 1992;45225- 227
Link to Article
McNulty  CADent  JCFord  GA  et al.  Inhibitory antimicrobial concentrations against Campylobacter pyloridis in gastric mucosa. J Antimicrob Chemother. 1988;22729- 738
Link to Article
Oderda  GVaira  DHolton  J  et al.  Amoxycillin plus tinidazole for Campylobacter pylori gastritis in children: assessment by serum IgG antibody, pepsinogen I, and gastrin levels. Lancet. 1989;1690- 692
Link to Article
Rauws  EAJLangenberg  WHouthoff  HJ  et al.  Campylobacter pyloridis– associated chronic active antral gastritis: a prospective study of its prevalence and the effects of antibacterial and antiulcer treatment. Gastroenterology. 1988;94229- 238
Marshall  BJ Treatment strategies for Helicobacterpylori infection. Gastroenterol Clin North Am. 1993;22183- 198
Goddard  AFMohamed  JJBarrett  DA  et al.  Effect of omeprazole on the distribution of metronidazole, amoxicillin, and clarithromycin in human gastric juice. Gastroenterology. 1996;111358- 367
Link to Article
Goodwin  CSMarshall  BJBlincow  ED  et al.  Prevention of nitroimidazole resistance in Campylobacter pylori by coadministration of colloidal bismuth subcitrate: clinical and in vitro studies. J Clin Pathol. 1988;41207- 210
Link to Article
Bell  GDPowell  KUBurridge  SM  et al.  Short report: omeprazole plus antibiotic combinations for the eradication of metronidazole-resistant Helicobacter pyloriAliment Pharmacol Ther. 1992;6751- 758
Link to Article
Glupczynski  YBurette  Ade Koster  E  et al.  Metronidazole resistance in Helicobacter pylori [letter]. Lancet. 1990;335976- 977
Link to Article
European Study Group on Antibiotic Susceptibility of Helicobacter pylori, Results of a multicenter European survey in 1991 of metronidazole resistance in Helicobacter pyloriEur J Clin Microbiol Infect Dis. 1992;11777- 781
Link to Article
Cederbrant  GKahlmeter  GLjungh  A Proposed mechanism for metronidazole resistance in Helicobacter pyloriJ Antimicrob Chemother. 1992;29115- 120
Link to Article
Marshall  BJGoodwin  CSWarren  JR  et al.  A prospective double-blind trial of duodenal ulcer relapse after eradication of Campylobacter pyloriLancet. 1988;21437- 1442
Link to Article
Chiba  NRao  BVRademaker  JWHunt  RH Meta-analysis of the efficacy of antibiotic therapy in eradicating HelicobacterpyloriAm J Gastroenterol. 1992;871716- 1727
Neri  MSusi  DBovani  I  et al.  Omeprazole, bismuth, and clarithromycin: a new approach to the treatment of H pylori–related gastritis [abstract]. Gastroenterology. 1992;102A134Taken From: Aliment Pharmacol Ther. 1994;8:469-471
Peterson  WLGraham  DLMarshall  B  et al.  Clarithromycin as monotherapy for eradication of Helicobacter pylori: a randomized, double-blind trial. Am J Gastroenterol. 1993;881860- 1864
Foulds  GShepard  RMJohnson  RB The pharmacokinetics of azithromycin in human serum and tissues. J Antimicrob Chemother. 1990;25 ((suppl A)) 73- 82
Link to Article
Hardy  DJHanson  CWHensey  DM  et al.  Susceptibility of Campylobacter pylori to macrolides and fluoroquinolones. J Antimicrob Chemother. 1988;22631- 636
Link to Article
Glupczynski  YBurette  A Failure of azythromycin to eradicate Campylobacter pylori from the stomach because of acquired resistance during treatment [letter]. Am J Gastroenterol. 1990;8598- 99
Bertoni  GRomano  SNigrisoli  E  et al.  Triple therapy with azithromycin, omeprazole, and amoxicillin is highly effective in the eradication of Helicobacter pylori: a controlled trial versus omeprazole plus amoxicillin. Am J Gastroenterol. 1996;91258- 263
Prewett  EJNwokolo  CUHudson  M  et al.  The effect of GR122311X, a bismuth compound with H2-antagonist activity, on 24-hour intragastric acidity. Aliment Pharmacol Ther. 1991;5481- 490
Link to Article
McColm  AAMcLaren  AKlinkert  G  et al.  Ranitidine bismuth citrate: a novel antiulcer agent with different physicochemical characteristics and improved biological activity to a bismuth citrate-ranitidine admixture. Aliment Pharmacol Ther. 1996;10241- 250
Link to Article
Webb  DDCiociola  AAPerschy  TB  et al.  Effect of administration of ranitidine bismuth citrate with food on the suppression and eradication of Helicobacter pylori in infected volunteers. Am J Gastroenterol. 1995;901273- 1277
Bardhan  KDDekkers  CPMLam  SK  et al.  GR122311X (ranitidine bismuth citrate), a new drug for the treatment of duodenal ulcer. Aliment Pharmacol Ther. 1995;9497- 506
Link to Article
Peterson  WLCiociola  AASykes  DL  et al.  Ranitidine bismuth citrate plus clarithromycin is effective for healing duodenal ulcer, eradicating H pylori, and reducing ulcer recurrence. Aliment Pharmacol Ther. 1996;10251- 261
Link to Article
Dixon  JS Helicobacter pylori eradication: unravelling the facts. Scand J Gastroenterol. 1995;30 ((suppl 212)) 48- 62
Link to Article
Morgando  ATodros  LBoero  M  et al.  Therapy of Helicobacter pylori infection: clinical trials with double and triple pharmacological association. Ital J Gastroenterol. 1991;23 ((suppl 2)) 112
Susi  DBovani  INeri  MCuccurullo  F The eradication of Helicobacter pylori depends on the depth of mucosal invasion: an electronmicroscopical study. Ital J Gastroenterol. 1991;23 ((suppl 2)) 67- 68
Mannes  GABayerdorffer  EHochter  W  et al.  Decreased relapse rate after antibacterial treatment of Helicobacterpylori–associated duodenal ulcers: Munich Duodenal Ulcer Trial. Eur J Gastroenterol Hepatol. 1993;5145- 153
Link to Article
Axon  A The role of omeprazole and antibiotic combinations in the eradication of Helicobacter pyloriScand J Gastroenterol. 1994;29 ((suppl 205)) 31- 37
Link to Article
Bayerdorffer  EMannes  GASommer  A  et al.  Long-term follow up after eradication of Helicobacter pylori with a combination of omeprazole and amoxycillin. Scand J Gastroenterol. 1993;28 ((suppl 196)) 19- 25
Link to Article
Mannes  GABayerdorffer  EHochter  W  et al.  An increasing dose of omeprazole combined with amoxycillin increases the eradication of Helicobacter pylori [abstract]. Gastroenterology. 1993;104A140
Chiba  NWilkinson  JMHunt  RH Clarithromycin (C) or amoxicillin (A) dual and triple therapies in H pylori (Hp) eradication: a meta-analysis [abstract]. Gut. 1995;37 ((suppl 2)) 31
Link to Article
Malaty  HEl-Zimaity  HMTGenta  RM  et al.  High dose proton pump inhibitors plus amoxycillin for the treatment or retreatment of Helicobacter pylori infection. Aliment Pharmacol Ther. 1996;1001- 1004
Labenz  JLeverkus  FBōrsch  G Omeprazole plus amoxycillin for cure of H. pylori infection: factors influencing the treatment success. Scand J Gastroenterol. 1994;291070- 1075
Link to Article
Abramowicz  Med Clarithromycin and omeprazole for Helicobacter pyloriMed Lett. 1996;3851- 52
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