Efficacy of Helicobacter pylori eradication therapies: a single centre observational study

Abstract

Background: Many Helicobacter pylori eradication regimens have been described. There are little data reporting their efficacy or integration in routine clinical practice. The overall results of eradication therapy in a cohort of patients are described and an algorithm for management outlined.

Methods: 469 patients receiving eradication therapy in routine clinical practice were evaluated. The successes of individual regimes as first, second and third line therapy were determined.

Results: Overall success after one, two and three courses of therapy were 73% (95% confidence intervals 69-77%), 94% (91-96%) and 98% (97-99%) respectively. 10 different regimens, including many non-recommended ones were used as primary therapy. Ranitidine bismuth citrate-amoxicillin-clarithromycin triple therapy (94.8%, 90-99%) was significantly more effective than any other combination as primary therapy, including all proton pump inhibitor based triple therapies. Quadruple therapy with bismuth chelate-proton pump inhibitor-tetracycline and a nitroimidazole (70%, 52-88%) and ranitidine bismuth citrate-based triple therapy (73%, 56-90%) where more effective second line combinations than proton pump inhibitor-triple therapies (37.5%, 12-58%). Third line therapy directed by the results of sensitivity testing improved eradication compared to further empirical antibiotics. The use of a proton pump inhibitor with clarithromycin and a nitroimidazole as initial therapy was associated with a significantly worse overall eradication rate than other combinations.

Conclusions: Helicobacter pylori eradication rates can be maximised by using ranitidine bismuth citrate-clarithromycin-amoxicillin containing triple therapy, followed by bismuth and nitroimidazle containing second-line therapy, with third line combinations directed by sensitivity testing. Proton pump inhibitor-clarithromycin-metronidazole combinations should be avoided.

Figure 1

Choice of second line therapies after first line failures. Lines indicate number of patients receiving each regimen after initial failures. Abbreviations used in figure: PPI-proton pump inhibitor, A-amoxicillin, C-clarithromycin, N-nitroimidazole, RBC-ranitidine bismuth citrate, DTB-tripostassium dicitratobismuthate, T-tetracycline, e-erythromycin

Figure 2

Suggested algorithm for eradication therapy in H. pylori infection. Regimens in parentheses are alternatives at each stage. ^*PPI+rifabutin+amoxicillin can be used when sensitivity testing is unavailable. ^**Isolates sensitive to both clarithromycin and metronidazole can be treated with RBC-C-T. Abbreviations used in the figure: A-amoxicillin, C-clarithromycin, T-tetracycline, N-nitroimidazole, M-metronidazole, PPI-proton pump inhibitor, RBC-ranitidine bismuth citrate.