High rate of Helicobacter pylori eradication with sequential therapy in elderly patients with peptic ulcer: a prospective controlled study

Bleeding peptic ulcer in the elderly: risk factors and prevention strategies

Peptic ulcer bleeding is a frequent and dramatic event with both a high mortality rate and a substantial cost for healthcare systems worldwide. It has been found that age is an independent predisposing factor for gastrointestinal bleeding, with the risk increasing significantly in individuals aged>65 years and increasing further in those aged>75 years. Indeed, bleeding incidence and mortality are distinctly higher in elderly patients, especially in those with co-morbidities. NSAID therapy and Helicobacter pylori infection are the most prevalent aetiopathogenetic factors involved in peptic ulcer bleeding. The risk of bleeding seems to be higher for NSAID- than for H. pylori-related ulcers, most likely because the antiplatelet action of NSAIDs impairs the clotting process. NSAID users may be classified as low or high risk, according to the absence or presence of one or more of the following factors associated with an increased risk of bleeding: co-morbidities; corticosteroid or anticoagulant co-therapy; previous dyspepsia, peptic ulcer or ulcer bleeding; and alcohol consumption. Different types of NSAIDs have been associated with different bleeding risk, but no anti-inflammatory drug, including selective cyclo-oxygenase (COX)-2 inhibitors, is completely safe for the stomach. Furthermore, even low-dose aspirin (acetylsalicylic acid) [<325 mg/day] and a standard dose of non-aspirin antiplatelet treatment (clopidogrel or ticlopidine) have been found to cause bleeding and mortality. No clear risk factor favouring H. pylori-related ulcer bleeding has been identified. Peptic ulcer bleeding prevention remains a challenge for the physician, but data are now available on use of a safer and cheaper strategy for both low- and high-risk patients. Unfortunately, despite the fact that several society and national guidelines have been formulated, these are poorly followed in clinical practice. Proton pump inhibitor (PPI) or misoprostol therapy and H. pylori eradication in NSAID-naive patients are the most commonly proposed strategies. Selective COX-2 inhibitor therapy in high-risk patients has also been suggested, but concerns over the possible cardiovascular adverse effects of some of these agents should be taken into account. Moreover, switching to selective COX-2 inhibitors in patients with previous bleeding is not completely risk free, and concomitant PPI therapy is also needed. H. pylori eradication is mandatory in all patients with peptic ulcer, and such an approach has been found to be significantly superior to PPI maintenance therapy. H. pylori eradication is frequently achieved with sequential therapy in elderly patients with peptic ulcer. In conclusion, upper gastrointestinal bleeding is a dramatic event with a high mortality rate, particularly in the elderly. Some effective preventative strategies are now available that should be implemented in clinical practice.

Treatment of Helicobacter pylori

Since the discovery of Helicobacter pylori in the early 1980s many treatment regimes have been developed to effectively treat this infection. International guidelines have allowed consensus on the best management and improved eradication rates. In recent years, increasing antimicrobial resistance has resulted in falling eradication rates with standard therapies. In this article, we review the most recent studies and guidelines in the treatment of H. pylori. Currently, the first-line treatment remains clarithromycin, amoxicillin or metronidazole and proton pump inhibitor twice daily, but a number of recent studies have shown low eradication rates with this treatment. Increased duration of therapy has been recommended to overcome the falling eradication rates. However, conflicting findings have been reported on the benefits of extending the length of traditional therapy. Sequential therapy may be an effective alternative to standard triple therapy in regions of increased antimicrobial resistance. Probiotics reduce side-effects from traditional regimens and may improve eradication rates. A quinolone-based second-line triple therapy appears to be effective and well tolerated. Bismuth-based quadruple therapy is also an effective alternative if available. In the future, regional antimicrobial resistance and eradication rates will determine the best treatment for H. pylori.

Helicobacter pylori: testing and treatment

Helicobacter pylori is an important pathogen worldwide. Accurate diagnosis and appropriate therapy is important in clinical practice. Invasive tests that accurately identify current infection include the biopsy urease test and histology. The best noninvasive tests for diagnosis include the urea breath test and stool antigen testing. Proton pump inhibitor therapy can lead to false-negative H. pylori test results, and treatment should be stopped for 1-2 weeks prior to testing if possible. In the setting of bleeding peptic ulcer disease, urea breath testing is recommended to rule out a false-negative biopsy test result if needed. The current recommendations for when to test for H. pylori vary around the world. Well-accepted indications include active and past ulcer disease, and gastric-mucosa associated lymphoid tissue lymphoma. There is no universal agreement regarding whether all patients with functional dyspepsia should be tested and treated, although this is an evidence-based recommendation. There is also evidence that H. pylori eradication prevents peptic ulcer disease in those starting NSAIDs long term. Primary treatment remains triple therapy with 10-14 days probably being superior to shorter courses of therapy. Quadruple therapy is recommended if standard triple therapy fails. Salvage therapies with levofloxacin, rifabutin or furazolidone have been identified. Novel approaches to treatment include sequential therapy and use of adjuvants.

American College of Gastroenterology guideline on the management of Helicobacter pylori infection

Helicobacter pylori (H. pylori) remains a prevalent, worldwide, chronic infection. Though the prevalence of this infection appears to be decreasing in many parts of the world, H. pylori remains an important factor linked to the development of peptic ulcer disease, gastric malignanc and dyspeptic symptoms. Whether to test for H. pylori in patients with functional dyspepsia, gastroesophageal reflux disease (GERD), patients taking nonsteroidal antiinflammatory drugs, with iron deficiency anemia, or who are at greater risk of developing gastric cancer remains controversial. H. pylori can be diagnosed by endoscopic or nonendoscopic methods. A variety of factors including the need for endoscopy, pretest probability of infection, local availability, and an understanding of the performance characteristics and cost of the individual tests influences choice of evaluation in a given patient. Testing to prove eradication should be performed in patients who receive treatment of H. pylori for peptic ulcer disease, individuals with persistent dyspeptic symptoms despite the test-and-treat strategy, those with H. pylori-associated MALT lymphoma, and individuals who have undergone resection of early gastric cancer. Recent studies suggest that eradication rates achieved by first-line treatment with a proton pump inhibitor (PPI), clarithromycin, and amoxicillin have decreased to 70-85%, in part due to increasing clarithromycin resistance. Eradication rates may also be lower with 7 versus 14-day regimens. Bismuth-containing quadruple regimens for 7-14 days are another first-line treatment option. Sequential therapy for 10 days has shown promise in Europe but requires validation in North America. The most commonly used salvage regimen in patients with persistent H. pylori is bismuth quadruple therapy. Recent data suggest that a PPI, levofloxacin, and amoxicillin for 10 days is more effective and better tolerated than bismuth quadruple therapy for persistent H. pylori infection, though this needs to be validated in the United States.

A report card to grade Helicobacter pylori therapy

Helicobacter pylori causes a serious bacterial infectious disease, and the expectations of therapy should reflect this fact. Increasing antibiotic resistance, especially to clarithromycin, has significantly undermined the effectiveness of legacy triple therapy consisting of a proton pump inhibitor, clarithromycin, and amoxicillin. Current cure rates are consistently below 80% intention-to-treat, the accepted threshold separating acceptable from unacceptable treatment results. Grading clinical studies into effectiveness categories using prespecified criteria would allow clinicians to objectively identify and compare regimens. We offer a therapy report card similar to that used to grade the performance of school children. The intention-to-treat cure rate categories are: F or unacceptable ( 80%), D or poor (81-84%), C or fair (85-89%), B or good (90-95%), and A or excellent (95-100%). The category of "excellent" is based on the cure rates expected with other prevalent bacterial infectious diseases. We propose that only therapies that score "excellent" (grade = A) should be prescribed. Regimens scoring as B or "good" can be used if "excellent" results are not obtainable. In most regions legacy triple therapy should be abandoned as unacceptable. Quadruple therapy and sequential therapy are reasonable alternatives for initial therapy.

Primary antibiotic resistance in Helicobacter pylori strains isolated in northern and central Italy

BACKGROUND

Helicobacter pylori resistance to antibiotics is increasing worldwide, and it reduces the efficacy of therapy.

AIM

To assess current primary antibiotic resistance in H. pylori strains isolated in Italy.

METHODS

Between June 2004 and June 2006, H. pylori strains were isolated consecutively in the two participating centres (Bologna, northern Italy; Rome, central Italy) from patients never previously treated for the infection. Isolated strains were tested for primary clarithromycin, metronidazole and levofloxacin resistance using as break point the minimal inhibitory concentration >/=1, >/=8 and >/=1 mg/L for the three antibiotics, respectively.

RESULTS

Overall, 255 H. pylori strains were evaluated. The resistance rate was 16.9% for clarithromycin, 29.4% for metronidazole and 19.1% for levofloxacin. Clarithromycin resistance was significantly higher in non-ulcer dyspepsia than in peptic ulcer patients (19.1% vs. 0%, P = 0.02), metronidazole resistance was higher in foreign than Italian patients (50% vs. 22.9%, P = 0.0004) and levofloxacin resistance was higher in old than younger patients (28.4% vs. 14.4%, P = 0.048). Levofloxacin resistance was also more frequent in those strains with either clarithromycin or metronidazole resistance.

CONCLUSION

A very high rate of primary resistance towards the tested antibiotics was detected in our study.

Effective regimens for the treatment of Helicobacter pylori infection

Successful Helicobacter pylori eradication therapy remains a challenge in medical practice. Currently, a proton pump inhibitor-based triple therapy containing clarithromycin, amoxicillin or nitroimidazole for 7 days is the recommended first-line treatment approach with an expected eradication success rate of approximately 80%. As a second-line treatment option in the case of failure, a ranitidine bismuth citrate-based quadruple therapy is currently recommended curing another 80% of patients, leaving a subset of patients with persistent H. pylori infection. For these patients, promising rescue options have been evaluated including regimens that contain rifabutin, quinolones, furazolidone or high-dose amoxicillin. The role of susceptibility testing is still under discussion. It is not generally recommended prior to first-line treatment but guidelines propose a role for culture and antibiotic sensitivity testing after failure of the second attempt. Meanwhile, data on the geographic distribution of resistance pattern are available and may guide therapeutic decisions with regard to the combination of antibiotics chosen for the individual patients aiming at 100% cure rate in each individual patient.

How to proceed in Helicobacter pylori-positive chronic gastritis refractory to first- and second-line eradication therapy

Helicobacter pylori is a widespread disease causing most of the peptic ulcer diseases and low-grade mucosa-associated lymphoreticular tissue (MALT) lymphoma. Moreover, H. pylori is a proven environmental risk factor for gastric carcinoma and it has been recognized as a type 1 carcinogen factor. A combination of drugs has been proposed, using a proton pump inhibitor (PPI), amoxicillin, clarithromycin, metronidazole and tetracycline to treat the infection. Since 1996, according to the European guidelines, the first-line approach using PPI, amoxicillin and clarithromycin or metronidazole has been suggested. Seven days of quadruple therapy with PPI (or ranitidine), tetracycline, bismuth salts and metronidazole has been reserved as second-line treatment. To improve the eradication rate of the triple therapy, a different combination of the available antibiotics has been proposed, consisting of a 10-day sequential regimen. A second-line levofloxacin-amoxicillin-based triple therapy given for 10 days has been proposed, obtaining a high eradication rate, suggesting this regimen to be a suitable retreatment option in eradication failure. A third-line treatment with rifabutin-based regimen has been proposed.

Sequential therapy using high-dose esomeprazole-amoxicillin followed by gatifloxacin for Helicobacter pylori infection

BACKGROUND

The success rate of current anti-Helicobacter pylori triple therapies in now generally 80% or less. Sequential therapy has proved superior.

AIM

To test a new sequential therapy for H. pylori eradication.

METHODS

This was a pilot study of a sequential therapy consisting of 40 mg of esomeprazole and 1 g amoxicillin t.d.s., for 12 days. On days 6 through 12 gatifloxacin (400 mg in the morning) was added. Outcome was accessed 4 or more weeks after ending antibiotic therapy. Both naive and treatment failures were eligible.

RESULTS

Thirty patients were entered in the study. One was lost to follow-up and one stopped early because of side effects. The success rate intention-to-treat was 80% (95% CI: 61-92%). The per-protocol eradication rate was 85.7% (95% CI: 67-95%); two of the four failures had pre-treatment gatifloxacin-resistant H. pylori. Side effects were reported by 13 patients (46%) and were generally mild with diarrhoea being most common (n = 6). Only one patient stopped medicine because of side effects of dizziness (severe) and diarrhoea (mild).

CONCLUSIONS

Sequential therapy using the combination of a high dose of proton-pump inhibitor and amoxicillin followed gatifloxacin was effective, but pre-treatment susceptibility testing may become necessary as fluoroquinolone resistance increases.

Helicobacter pylori diagnosis and management

H pylori is a global human pathogen and is the major cause of gastritis and the gastritis-associated diseases: gastric ulcer, duodenal ulcer, gastric cancer, and primary gastric B-cell lymphoma (MALToma). Although several reliable diagnostic tests are widely available, the ideal regimen for treating the infection re-mains to be established. The current first-line or legacy triple therapy regimens fail in 20% to 40% of patients. Causes of treatment failure include antibiotic resistance, poor compliance, short (7-10 days) duration of therapy, and drug-related side effects. Fourteen-day triple therapy has an approximately 12% better cure rate than does 7-day therapy; therefore, shorter durations can no longer be recommended. Recent studies confirmed older observations that the success rate of legacy triple regimens (PPI plus two antibiotics) can be improved if the duration is extended to 14 days or if a third antibiotic is given. Sequential therapy (PPI plus amoxicillin followed by a PPI plus clarithromycin plus metronidazole) requires further evaluation although the concept appears very promising and therapy should probably replace the legacy triple therapies. More studies are needed to examine doses, durations, and the need for sequential administration of the drugs, which extends the duration to 14 days. Nonetheless, sequential quadruple therapy probably should replace the legacy triple therapies. Classic quadruple therapy contains bismuth, a PPI, 1500 mg of metronidazole, and 1500 mg of tetracycline. It provides the highest average eradication rates and in many regions should be considered as the initial approach. Confirmation of eradication using noninvasive diagnostic tests, such as a urea breath test or stool antigen assay, is now the standard of care. The diagnosis of latent or symptomatic H pylori like the diagnosis of latent or symptomatic syphilis, always should prompt treatment. Because of decreasing cure rates, new and improved therapies are needed.

Second-line treatment for Helicobacter pylori eradication after sequential therapy failure: a pilot study

A 64-year-old woman was admitted to the hospital for abdominal fullness and constipation. In the pelvic cavity, an abdominal CT scan revealed massive ascites showing malignancy on histological examination. Upper GI endoscopy revealed type 3 gastric cancer from the anglus to the cardia. A barium-enema showed a stenotic lesion at the sigmoid colon due to peritoneal dissemination. An abnormally high CA125(1,400 mg/ml) level was detected in serum. We performed systemic chemotherapy of TS-1, CDDP and peritoneal infusion of docetaxel on the nonresected gastric cancer with peritoneal dissemination. After 2 cycles, cytology of ascites revealed no malignancy, and the serum CA125 value regained its normal level. After 3 cycles, the killer cell effect was recognized by laparoscopic examination and the stenotic change of sigmoid colon had almost disappeared. The patient clinically achieved good QOL by this method, which was very effective for nonresected gastric cancer with peritoneal dissemination.