Towards an Individualised Treatment of Helicobacter pylori Infection

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Optimal treatment of H. pylori should produce cure rates of at least 90%, preferably 94% or greater per protocol. Initially, 14-day triple therapy was highly successful but clarithromycin resistance led to a fall in cure rates to 80% or less. Intelligent choice of empiric therapy requires knowledge of the local or regional patterns of drug resistance and monitoring the outcome of therapy to provide early warning of development of resistance. </p&gt;<p&gt; We recommend the following general rules 1) Do not use legacy triple therapy consisting of a PPI, clarithromycin and amoxicillin unless it has been proven to be highly effective locally; 2) Do not reduce the doses of commonly used antibiotics unless it has been shown that lower doses reliably produce eradication rates of 90% or greater; 3) The duration of therapy should be 14 days unless a shorter duration has been shown locally to produce equally high treatment success; 4) Following treatment failure avoid reuse clarithromycin or fluoroquinolones as resistance had likely developed and cannot be overcome by increasing the dose or duration of therapy; and 5) Avoid clarithromycin and fluoroquinolones in first line therapy if either has been used in the past even for a different indication. We recommend using four drug combinations as first line (i.e., concomitant, hybrid, or bismuth-containing regimens). Second-line therapy should consist of antimicrobials that have not been used previously. Salvage therapy (i.e., after 2 or more failures) should be chosen on the basis of the results of antimicrobial susceptibility testing.