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October 15th, 2012

ID Doctors are Clueless about Treating Helicobacter

Every so often, we’ll get a referral from a gastroenterologist about a refractory case of Helicobacter pylori.

Usually the patient has been treated multiple times, and still has symptoms and a positive test. Naturally a referral to a specialist in Infectious Diseases seems warranted.

But the reality is that this is like the IV nurse contacting the July intern with a tricky IV, telling the newly minted doc that since he/she (the nurse) can’t get the IV in, the intern should give it a try.

Ha.

Because the fact is that most ID doctors know little if anything about treating helicobacter, which is overwhelmingly diagnosed and managed by primary care doctors and gastroenterologists.

The ID doc can read the guidelines as well as the next guy, but we have little hands-on experience with treatment. So choosing between the multiple different regimens, selecting the right PPI and dose, giving the right length of therapy, and deciding whether to use bismuth are practical skills we most definitely lack. Suffice to say it’s no accident that this study was covered in Journal Watch Gastro rather than Journal Watch ID. 

I was reminded of this gap in our knowledge the other day with this exchange with one of my colleagues:

GI doc:  Hey Paul, I have a question about Helicobacter treatment.

Me:  OK …

[I'm worried. Should I tell him he might as well be asking his office receptionist?]

GI doc:  I saw your patient John Smith, he’s on HIV treatment with blank, blank, and blank.

[He horribly mangles the regimen, which is tenofovir/FTC and boosted darunavir. I'm feeling better already.]

Here’s my question — what can I give him that won’t interact?

Me:  Just avoid clarithromycin — it interacts with the darunavir and ritonavir.

[Amazingly, he's asked me about the only thing I could possibly answer about helicobacter without looking it up.]

GI doc: Fine, I’ll use Pylera.

[I have absolutely no idea what that is. Time to come clean.]

Me:  I have absolutely no idea what that is.

For the record, Pylera is a combination of bismuth, tetracycline, and metronidazole. Learn something new every day.

It’s pretty easy to understand why we know next to nothing about helicobacter — the disease used to require an endoscopy and biopsy for diagnosis. Regardless, it’s quite humbling to acknowledge that yes, there’s this fascinating (and very cool looking) bacterial infection out there about which most ID doctors have little if any expertise.

Perhaps that will change as rates of antibiotic resistance rise, especially if complex culturing and susceptibility testing are required. We’re really good at that stuff.

4 Responses to “ID Doctors are Clueless about Treating Helicobacter”

  1. G. Clarke says:

    metronidazole interacts with darunavir/r.

  2. Paul Sax says:

    G.,

    Re: the metronidazole and darunavir/r interaction — that’s only if you are using the ritonavir capsules or solution, both of which contain alcohol. There’s no significant interaction with darunavir/r when using ritonavir tablets — virtually all of our patients (including this one in the case above) are on tablets now.

    Paul

  3. Loretta S says:

    I love reading your blog entries, Paul. Your honesty and humbleness is appreciated. As a primary care provider, I will send my H. pylori refractory patients to a GI doc instead of an ID doc first! :)

  4. Jose A. Giron MD FACP says:

    I treat a good deal of H pylori mostly because I look for it. I keep my statistics which show a success rate of eradication, proven by stool H pylori
    antigen and clinical improvement, of over 95%.
    The key is to look for the pathogen.

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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