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The addition of bismuth subcitrate to a triple therapy that includes proton pump inhibitors, amoxicillin, and rifabutin in patients who are treated for the third time for H. pylori infection resulted in a 30% therapeutic gain.

Optimal therapy for Helicobacter pylori infection consists of a proton pump inhibitor in combination with metronidazole (or tinidazole) and clarithromycin. This therapy presents eradication rates of H. pylori from 70% up to 90% and few side-effects. 1, 2 However, antibiotic resistance jeopardizes the success of this regimen. 3, 4 A large number of studies have demonstrated the prevalence of H. pylori resistance to metronidazole and clarithromycin in various countries. In a recent European survey, resistance ranged from 10% to 50% for metronidazole and 0% to 15% for clarithromycin, whilst resistance to amoxicillin has also been reported but appears to be uncommon. 5,6 Several studies have evaluated the relationship between pre-treatment antibiotic resistance and eradication rate using different standard treatments and performing a susceptibility test before the initiation of the therapeutic regimen. These studies used standard treatments without taking into consideration the results of the susceptibility test; the impact of antibiotic resistance on eradication rate was calculated retrospectively. 7±10 To date there are no prospective studies that use culture and antibiotic susceptibility tests to choose a speci®c therapy for H. pylori eradication. The aim of this study has therefore been to examine whether a preliminary in vitro susceptibility test of SUMMARY Background: Helicobacter pylori treatment failure may be due to resistance to macrolides and 5-nitroimidazoles. Aim: To test whether a preliminary in vitro susceptibility test of H. pylori to tinidazole and clarithromycin and a consequent speci®c regimen could improve the eradication rate. Methods: A total of 109 consecutive H. pylori-positive patients with dyspeptic symptoms were included. At endoscopy, biopsy from the antrum was obtained for H. pylori culture and antimicrobial susceptibility testing. Fifty-six patients were treated with omeprazole, tinidazole and clarithromycin for 10 days (group OTC) and 53 patients received therapy on the basis of the suscepti-

This study underlines the high rate of resistance to clarithromycin, metronidazole and quinolones, which may reflect an overuse of them. Culture and susceptibility test, should be performed to prevent the emergence of multi-resistance and to assess an efficacious regimen.