Rational Helicobacter pylori Therapy: Evidence-Based Medicine Rather Than Medicine-Based Evidence

Abstract

Data are available such that choice of Helicobacter pylori therapy for an individual patient can be reliably predicted. Here treatment success is defined at a cure rate of 90% or greater. Treatment outcome in a population or a patient can be calculated based on the effectiveness of a regimen for infections with susceptible and with resistant strains coupled with knowledge of the prevalence of resistance (i.e., based on formal measurement, clinical experience, or both). We provide the formula for predicting outcome and we illustrate the calculations. Because clarithromycin-containing triple therapy and 10 day sequential therapy are now only effective in special populations they are considered obsolete; neither should continue to be used as empiric therapies (i.e., 7 and 14 day triple therapies fail when clarithromycin resistance exceeds 5% and 15%, respectively and 10-day sequential therapy fails when metronidazole resistance exceeds 20%). Therapy should be individualized base on prior history and whether the patient is in a high risk group for resistance. The preferred choices for Western countries are 14 day concomitant therapy, 14 day bismuth quadruple therapy, and 14 day hybrid sequential-concomitant therapy. We also provide details regarding the successful use of fluoroquinolone-rifabutin-, and furazolidone-containing therapies. Finally, we give recommendations for efficient development (i.e., identification and optimization) of new regimens as well as how to prevent or minimized failures. The trial and error approach for identifying and testing regimens frequently resulted in poor treatment success. The approach described allows outcome to be predicted and should simplify treatment and drug development.

The diagnosis and management of H. pylori infection in Singapore

“…(25) Resistance to clarithromycin, in particular, is responsible for a decrease in the efficacy of current triple-therapy regimens. (25)(26)(27) As antibiotic resistance profiles vary across geographical regions, knowledge of local resistance patterns and treatment outcomes is important. (26,28) A recent study of H. pylori resistance profiles in Singapore found that in the time periods of 2000-2002 and 2012-2014, resistance rates to clarithromycin (7.9% to 17.1%), metronidazole (24.8% to 48.2%) and levofloxacin (5.0 to 14.7%) have increased, whereas resistance to amoxicillin (3.0% to 4.1%) and tetracycline (5.0% to 7.6%) remained low.…”

Antibiotic treatment forHelicobacter pylori: Is the end coming?

“…Second, there are few data describing the effect of metronidazole resistance in concomitant therapy. Moreover if dual-resistance to clarithromycin and metronidazole was > 15%, the eradication rate decreased [108,109] . Finally, as with sequential therapy, when first-line treatment fails no second-line treatment for concomitant therapy has been established.…”

Trends in Secondary Antibiotic Resistance of Helicobacter pylori from 2007 to 2014: Has the Tide Turned?

“…The current guidelines recommend H. pylori culture and susceptibility testing following two unsuccessful courses of treatment (1). Nevertheless, in regions where antibiotic susceptibility testing is unavailable, epidemiological data for secondary H. pylori resistance is essential to allow for the rational use of antibiotics following several failures in treatment (2). In this manner, the treatment success of a particular antibiotic regimen can be reliably predicted based on epidemiological data, even in the absence of individualized H. pylori culture and susceptibility testing.…”