March 25th, 2011
H. pylori: Is it time to change our first-line treatment?
H. pylori dominated the GI news in the 1990s, and despite it disappearing from the front pages, it remains a common and important clinical problem. The dominant recommended initial treatment strategy has been a clarithromycin-based PPI triple therapy, with either amoxicillin or metronidazole as the third drug. This approach was based on clinical studies, ease of use, and tolerability factors. Bismuth-based quadruple therapy (a bismuth agent, metronidazole, tetracycline, and a PPI), despite demonstrating excellent activity, was usually relegated to second-line therapy because of the complexity of the dosing as well as compliance and tolerability issues.
However, duringthe last decade, the widespread use of macrolides in the general population has led to rising resistance to clarithromycin (by 30% or more of H. pylori strains in some areas), and when clarithromycin resistance is present, the efficacy of clarithromycin-containing triple therapy falls from about 80% to 50% or even lower. However, clarithromycin resistance does not affect the efficacy of bismuth-based quadruple therapy, and that efficacy of those regimens remains at about 90% when patients are compliant with the treatment.
So the questions for you to consider are:
1) Do you know what the clarithromycin resistance rate in H. pylori is in your community?
2) What first-line H. pylori treatment regimen do you use?
3) Are you planning to change your H. pylori treatment strategy now that clarithromycin resistance rates are rising?
Let us know what you think.
6 Responses to “H. pylori: Is it time to change our first-line treatment?”
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
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I agree it is a time to change the line of treatment for H.pylori. I felt and observed clerithromycin not effective and not giving required result.
2.I Use amoxacillin,metronedazole and PPI combination.
3 I need to change but want to discuss and share on this topic.
What is your take on the sequential therapy?
In my office resitance to triple therapy with Clarithromyce, ampicilin and omeprazole is of nearly 40%.
I use levofloxacin, amoxicilin and PPI as first line treatment with only 6% resistance ( for now…)
I don´t think change
I agree not only for resisitance but also for compliance.
Most of my cases I am using combination of– amoxicillin, levofloxacin and PPI
What is clear is that treatment failures are increasingly common with PPI + Amoxil + Clari and here in South Africa we have stopped using Metronidazole because of widespread resistance.
What is of concern is that bacteriologists do not seem to know what other antibiotics may be effective. When I sent for culture and sensitivity, a biopsy from a person who had failed to eradicate after 3 courses of treatment (including colloidal bismuth tetracycline etc)the only thing they could tell me was that the organism was resistant to Clari, which was already obvious! They said doing sensitivities to other antibiotics was very difficult?
I am currently using quadruple therapy as first line treatment due to significant resistance to Use amoxacillin,metronedazole and PPI combination. My choice is Omeprazole, Levofloxacin, Tinidazole and Bismuth