Review article: treatments that impact favourably upon the eradication of Helicobacter pylori and ulcer recurrence

Periodontal therapy as adjunctive treatment for gastric Helicobacter pylori infection

BACKGROUND

Helicobacter pylori is estimated to affect about half the world's population and is considered as the main cause of chronic gastritis and peptic ulcer disease. Eradication of H. pylori infection accelerates ulcer healing and prevents relapse, reducing incidence of H. pylori-related gastric diseases. Numerous studies have provided evidence that the oral cavity could be a potential reservoir for H. pylori. The presence of oralH. pylori might affect the efficiency of eradication therapy and act as a causal force for its recurrence. Conversely, other investigators have indicated that the colonization and growth of H. pylori differs between the oral cavity and the stomach. Considering the open debate on the topic, it's necessary to clarify whether periodontal therapy is an effective adjunctive treatment for gastric H. pylori infection.

OBJECTIVES

To assess the effects of periodontal therapy plus eradication therapy versus eradication therapy alone for gastric H. pylori infection. The secondary objective is to compare the non-recurrence rate at long-term follow up in different treatment groups.

SEARCH METHODS

We identified randomized controlled trials (RCTs) by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 8), MEDLINE (1946 to August 2015), EMBASE (1980 to August 2015), and the Chinese Biomedical Database (1978 to August 2015). We also searched both ClinicalTrials.gov and the WHO ICTRP portal in October 2015. We handsearched the reference lists of included studies to identify relevant trials.

SELECTION CRITERIA

RCTs comparing periodontal therapy plus eradication treatment with eradication treatment alone, regardless of language of publication.

DATA COLLECTION AND ANALYSIS

Two reviewers selected the trials that met the inclusion criteria and extracted the details of each study independently. The data were pooled using both fixed-effect and random-effects models and results calculated as odds ratios (OR) with their 95% confidence intervals (CIs) based on an intention-to-treat analysis. However, because there was little difference in the results from these two models, we only reported the results from the fixed-effect model.

MAIN RESULTS

We included seven small RCTs involving 691 participants aged 17 to 78 years in our meta analyses. The primary result showed that periodontal therapy combined with H. pylori eradication treatment increased the eradication rate of gastric H. pylori compared with eradication treatment alone (OR 2.15; 95% CI 1.47 to 3.14; P < 0.0001) in people with H. pylori infection. In addition, periodontal therapy also had benefits on long-term gastric H. pylori eradication. After eradication of H. pylori, the non-recurrence rate of gastric H. pylori infection increased in participants treated with periodontal therapy compared with those who received eradication therapy alone (OR 3.60; 95% CI 2.11 to 6.15; P < 0.00001). According to the GRADE approach, the overall quality of the evidence was 'moderate' for eradication rate of gastric H.pylori and 'low' for non-recurrence rate of gastric H. pylori.

AUTHORS' CONCLUSIONS

Overall, periodontal therapy could increase the efficiency of H. pylori eradication and the non-recurrence rate of gastricH. pylori. In view of the limited number and quality of included studies, it will be necessary to conduct more well-designed, multicenter, and large-scale RCTs to determine the effects of periodontal therapy in eradicating gastric H. pylori and suppressing the recurrence of this bacterium in the stomach.

Periodontal therapy as adjunctive treatment for gastric Helicobacter pylori infection

BACKGROUND

Helicobacter pylori is estimated to affect about half the world's population and is considered as the main cause of chronic gastritis and peptic ulcer disease. Eradication of H. pylori infection accelerates ulcer healing and prevents relapse, reducing incidence of H. pylori-related gastric diseases. Numerous studies have provided evidence that the oral cavity could be a potential reservoir for H. pylori. The presence of oralH. pylori might affect the efficiency of eradication therapy and act as a causal force for its recurrence. Conversely, other investigators have indicated that the colonization and growth of H. pylori differs between the oral cavity and the stomach. Considering the open debate on the topic, it's necessary to clarify whether periodontal therapy is an effective adjunctive treatment for gastric H. pylori infection.

OBJECTIVES

To assess the effects of periodontal therapy plus eradication therapy versus eradication therapy alone for gastric H. pylori infection. The secondary objective is to compare the non-recurrence rate at long-term follow up in different treatment groups.

SEARCH METHODS

We identified randomized controlled trials (RCTs) by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 8), MEDLINE (1946 to August 2015), EMBASE (1980 to August 2015), and the Chinese Biomedical Database (1978 to August 2015). We also searched both ClinicalTrials.gov and the WHO ICTRP portal in October 2015. We handsearched the reference lists of included studies to identify relevant trials.

SELECTION CRITERIA

RCTs comparing periodontal therapy plus eradication treatment with eradication treatment alone, regardless of language of publication.

DATA COLLECTION AND ANALYSIS

Two reviewers selected the trials that met the inclusion criteria and extracted the details of each study independently. The data were pooled using both fixed-effect and random-effects models and results calculated as odds ratios (OR) with their 95% confidence intervals (CIs) based on an intention-to-treat analysis. However, because there was little difference in the results from these two models, we only reported the results from the fixed-effect model.

MAIN RESULTS

We included seven small RCTs involving 691 participants aged 17 to 78 years in our meta analyses. The primary result showed that periodontal therapy combined with H. pylori eradication treatment increased the eradication rate of gastric H. pylori compared with eradication treatment alone (OR 2.15; 95% CI 1.47 to 3.14; P < 0.0001) in people with H. pylori infection. In addition, periodontal therapy also had benefits on long-term gastric H. pylori eradication. After eradication of H. pylori, the non-recurrence rate of gastric H. pylori infection increased in participants treated with periodontal therapy compared with those who received eradication therapy alone (OR 3.60; 95% CI 2.11 to 6.15; P < 0.00001). According to the GRADE approach, the overall quality of the evidence was 'moderate' for eradication rate of gastric H.pylori and 'low' for non-recurrence rate of gastric H. pylori.

AUTHORS' CONCLUSIONS

Overall, periodontal therapy could increase the efficiency of H. pylori eradication and the non-recurrence rate of gastricH. pylori. In view of the limited number and quality of included studies, it will be necessary to conduct more well-designed, multicenter, and large-scale RCTs to determine the effects of periodontal therapy in eradicating gastric H. pylori and suppressing the recurrence of this bacterium in the stomach.

New dual therapy for primary treatment of Helicobacter pylori infection: A prospective randomized study in Shanghai, China

OBJECTIVE

To evaluate the eradication rates, side effects and the patient compliance of a dual therapy with rabeprazole and amoxicillin as the first-line therapy in patients with Helicobacter pylori (H. pylori) infection.

METHODS

A total of 120 patients diagnosed endoscopically with non-ulcer dyspepsia with H. pylori infection were randomly assigned into two groups, one treated with amoxicillin 1 g thrice daily plus rabeprazole 10 mg twice daily (R10A group) or 20 mg twice daily (R20A group) for 14 days. H. pylori eradication was evaluated by (13) C-urea breath test (UBT) at 4-6 weeks after the completion of treatment. H. pylori eradication rate was analyzed by per-protocol (PP) and intention-to-treat (ITT) analyses together with 95% confidence interval (CI). Side effects and patients' compliance were also recorded.

RESULTS

Overall, 117 patients (58 in the R10A group and 59 in the R20A group) completed the study, among whom five did not undertake the UBT. H. pylori eradication was achieved in 89.8% of patients in the R20A group by ITT analysis and 93.0% by PP analysis, which was significantly higher than those in the R10A group (75.9% and 80.0%, respectively, P < 0.05). Side effects, including skin rash, abdominal discomfort, headache, insomnia and nausea, were all mild and were treated symptomatically without the need to discontinue the treatment.

CONCLUSION

The modified dual therapy with high doses of rabeprazole and amoxicillin is considered an effective and safe primary therapy for H. pylori eradication and could be recommended as the first-line eradication regimen for certain patients.

Role of omeprazole dosage and cytochrome P450 2C19 genotype in patients receiving omeprazole-amoxicillin dual therapy for Helicobacter pylori eradication

STUDY OBJECTIVE

To determine the factors that may influence Helicobacter pylori eradication in patients receiving omeprazole-amoxicillin dual therapy.

DESIGN

Prospective, randomized study.

SETTING

University-affiliated hospital in Taiwan.

PATIENTS

A total of 128 adults (age range 20-75 yrs) with H. pylori-positive duodenal ulcer were enrolled; 121 completed the final evaluation.

INTERVENTION

Patients were randomly assigned to one of four omeprazole-amoxicillin treatment groups, with each treatment administered for 2 weeks: O2A2 group (33 patients)--omeprazole 20 mg twice/day plus amoxicillin 500 mg 4 times/day; O2A1 group (32 patients)--omeprazole 20 mg twice/day plus amoxicillin 250 mg 4 times/day; O1A2 group (32 patients)--omeprazole 20 mg once/day plus amoxicillin 500 mg 4 times/day; and O1A1 group (31 patients)--omeprazole 20 mg once/day plus amoxicillin 250 mg 4 times/day.

MEASUREMENTS AND MAIN RESULTS

Data were collected on H. pylori status, histologic parameters, antibiotic resistance, intragastric pH, cytochrome P450 (CYP) 2C19 genotype, and adverse reactions. The intent-to-treat cure rates (95% confidence interval [CI]) in groups O2A2, O2A1, O1A2, and O1A1 were 76% (95% CI 59-87%), 72% (95% CI 54-84%), 50% (95% CI 34-66%) and 52% (95% CI 35-68%), respectively. Eradication of H. pylori infection was statistically significantly dependent on omeprazole dosage, CYP2C19 genotype, age, gastritis status, and H. pylori density. All CYP2C19 poor metabolizers were cured, whereas the H. pylori cure rate in CYP2C19 extensive metabolizers varied from 44-76% in the different treatment groups. Eradication of H. pylori was favored in the omeprazole higher dose groups versus the lower dose groups (79% vs 53%, p=0.004). No secondary antibiotic resistance was found. Thirty-seven (95%) of 39 patients who failed with the initial treatment were cured by subsequent antibiotic susceptibility-driven proton pump inhibitor-based triple therapy.

CONCLUSION

Provided a maintenance dose of amoxicillin is given every 6 hours, eradication of H. pylori infection was significantly dependent on omeprazole dosage, CYP2C19 genotype, age, gastritis status, and H. pylori density.

Influence of pretreatment with H2 receptor antagonists on the cure rates of Helicobacter pylori eradication

Background

Pretreatment with a proton pump inhibitor (PPI) reportedly decreases the efficacy of Helicobacter pylori (H. pylori) eradication, however, the effect of pretreatment with an H2 receptor antagonist (H2RA) on H. pylori eradication has not yet been studied. We compared the efficacy of eradication regimen (lansoprazole/amoxicillin/clarithromycin) in patients with H. pylori infection with or without H2RA pretreatment.

Material/Methods

In this retrospective study conducted at three centers, 310 patients with H. pylori infection were treated. The diagnosis of H. pylori infection was made using the rapid urease test, bacterial cultures and histological examination of endoscopic biopsy specimens. The patients were assigned to receive an eradication regimen first or following pretreatment with H2RA. Eradication was assessed using the ¹³C-urea breath test more than 4 weeks after the completion of therapy.

Results

Overall, H. pylori was eradicated in 79.7% of the cases: the eradication rate was 81.6% in the pretreatment group, and 77.6% in the eradication first group (p=0.3799, chi-square test). No significant difference in the eradication rate was observed between the two groups.

Conclusions

Pretreatment with H2RA had no significant influence on the efficacy of H. pylori eradication therapy.

Antimicrobial therapy of peptic ulcers

It is now accepted that peptic ulcer disease, whether duodenal or gastric, is one manifestation of infection with the bacterium Helicobacter pylori. This realization has revolutionized the management of peptic ulcer disease and changed the dictum from no acid no ulcer, to no H. pylori, no ulcer. When confronted with a patient with peptic ulcer disease, the physician must now ask whether H. pylori infection is present and if so, attempt to cure it. The gastric milieu is a very difficult environment for effective antimicrobial therapy. Nevertheless, current multi-drug antimicrobial therapy can be expected to cure the infection in more than 80% of patients. Cure of the infection is associated with a very low rate of recurrence. The continued risk of serious disease or disease complications associated with treatment failure and the availability of the urea breath test to non-invasively assess the results of therapy suggest that post therapy assessment should be routine. Because H. pylori infection causes structural and functional damage to the stomach and is associated with a lifetime risk of peptic or gastric cancer of approximately 16 and 1%, respectively, the infection should be treated whenever it is diagnosed. This paper reviews the current approach to therapy of patients with H. pylori infection, the effective antimicrobial drug combinations end the factors that predict treatment failure. Emergence of antimicrobial resistance may soon undermine the effectiveness of current drug regimens and require pretreatment culture and sensitivity testing as well as development of new drugs and drug regimens.

Short-duration furazolidone therapy in combination with amoxicillin, bismuth subcitrate, and omeprazole for eradication of Helicobacter pylori

BACKGROUND/AIM

Resistance to metronidazole is one of the most common reasons for Helicobacter pylori treatment failure with the classic triple therapy. The clarithromycin-based regimen is not cost-effective for use in developing countries. Though furazolidone is a great substitute it has many side effects. Decreasing the duration of treatment with furazolidone to 1 week may help decrease the drug's side effects.

AIM

To study the efficacy and side effects of furazolidone when given for 1 week in combination with bismuth subcitrate, amoxicillin, and omeprazole.

MATERIALS AND METHODS

One hundred and seventy-seven patients with duodenal ulcer were randomly divided into two groups. Group I received omeprazole 2 Chi 20 mg + amoxicillin 2 Chi 1 g + bismuth subcitrate 4 Chi 120 mg for 2 weeks, with furazolidone 2 Chi 200 mg in the first week only. Group II received the same regimen, except that 1 week of furazolidone was followed by 1 week of metronidazole in the second week. Control endoscopy was performed after 6 weeks. Three biopsies from the antrum and three from the corpus were taken for urease testing and histology. Eradication was concluded if all tests were negative for H pylori.

RESULTS

One hundred and fifty-seven patients completed the study. Two subjects from group I and three from group II did not tolerate the regimen and were excluded from the analysis. No serious complication was detected in any patient. The eradication rates by per-protocol (PP) analysis and intention-to-treat (ITT) analysis were 89% and 79.3% in group I and 86.6% and 74.4% in group II, respectively.

CONCLUSION

One week of furazolidone in combination with 2 weeks of amoxicillin, omeprazole, and bismuth subcitrate is a safe and cost-effective regimen for the eradication of H pylori. Adding metronidazole to the above regimen does not increase the eradication rate.

Moxifloxacine plus amoxicillin and ranitidine bismuth citrate or esomeprazole triple therapies for Helicobacter pylori infection

Up to 20% of patients, or even more, will fail to obtain eradication after a standard triple therapy. The aim of this study is to evaluate the efficacy of moxifloxacine-containing regimens in the first-line treatment of Helicobacter pylori. One hundred and twenty H. pylori-positive patients were randomized into four groups to receive one of the following 14-day treatments: ranitidine bismuth citrate (RBC) 400 mg b.d. plus amoxicillin 1 g b.d. and clarithromycin 500 mg b.d. (RAC group, n = 30); RBC 400 mg b.d. plus moxifloxacine 400 mg o.d. and amoxicillin 1,000 mg b.d. (RAM group, n = 30); esomeprazole 40 mg b.d. plus amoxicillin 1,000 mg b.d. plus clarithromycin 500 mg b.d. (EAC group, n = 30); and esomeprazole 40 mg b.d. plus amoxicillin 1,000 mg b.d. plus moxifloxacine 400 mg o.d. (EAM group, n = 30). Eradication was assessed by (13)C urea breath test 8 weeks after therapy. Per-protocol and intention-to-treat eradication was achieved in 23 out of 30 patients (76.7%, 95% confidence interval [CI]: 61-92) in the RAC group, in 20 patients (66.7%, 95% CI: 49-84) in the RAM group, in 16 patients in the EAM group (53.3%, 95% CI: 34-71), and in 19 patients in the EAC group (63.3%, 95% CI: 54-72). Mild or moderate side-effects were significantly more common in the EAM group (70%) compared to the RAC (36.6%), RAM (43.3%), and EAC (56.6%) groups (P = 0.03). From our results, we conclude that moxifloxacine-containing triple therapies have neither eradication nor compliance advantages over standard triple therapies. Further studies with new antibiotic associations are needed for the better eradication of H. pylori in developing regions of the world.

No Helicobacter pylori, no Helicobacter pylori-associated peptic ulcer disease

Virtually all duodenal ulcers (DUs) and the vast majority of gastric ulcers (GUs) are the consequence of Helicobacter pylori-associated inflammation. In DUs, the inflammation is maximal in the antrum and is associated with gastric metaplasia in the bulb. Gastrin homeostasis is disturbed by H. pylori gastritis and there is robust acid secretion. Successful eradication of the infection cures the ulcer diathesis. Amalgamated figures for ulcer relapse per year in H. pylori-positive DUs are > 60% compared with 2.6% for H. pylori-negative DU patients. The corresponding figures for GU are > 50% for H. pylori-positive and 2.0% for H. pylori-negative individuals. This striking difference in relapse rate persists, as the re-infection rate in the developed world is < 1% per year. Recurrent bleeding in bleeding-prone DUs is essentially abolished after cure of the infection. Proton pump inhibitors (PPIs) are increasingly used in eradication regimens. PPIs have intrinsic antimicrobial activity. MICs for lansoprazole (LAN) are lower than for omeprazole (OME). Two weeks of triple therapy (bismuth, tetracycline, imidazole) has, on average, a superior eradication efficacy (> or = 90%) compared with dual therapy (PPI, amoxycillin or clarithromycin) (> or = 80%). When a combination of PPI and two antibiotics has been used, results comparable to triple therapy have been reported. However, the side-effects profile and patient acceptability of PPI plus one or two antibiotic regimens are better than for traditional triple therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Improvement in symptoms after H2-receptor antagonist-based therapy for eradication of H pylori infection

AIM: To investigate the therapeutic effects of triple therapy combining lafutidine with clarithromycin and amoxicillin on H pylori infection and the resolution of gastroesophageal symptoms after eradication.

METHODS: We conducted a randomized, multicenter, open-label controlled trial to compare the effectiveness of a triple therapy of lafutidine, clarithromycin, and amoxicillin (lafutidine group) with that of a triple therapy of lansoprazole, clarithromycin, and amoxicillin (lansoprazole group) in patients with H pylori infection. The study group comprised 22 patients with gastric ulcers and 18 patients with duodenal ulcers who had H pylori infection.

RESULTS: H pylori eradication rates were similar in the lafutidine group (14/20, 70%) and the lansoprazole group (14/20, 70%). Gastroesophageal reflux and abdominal symptoms improved after eradication therapy in both groups, whereas abdominal discomfort, diarrhea, and constipation were unchanged. H pylori status had no apparent effect on improvement of gastroesophageal reflux or abdominal symptoms after treatment. Adverse events were similar in both groups.

CONCLUSION: The triple therapy including lafutidine is equivalent to triple therapy including lansoprazole in terms of H pylori eradication rates and improvement in gastroesophageal reflux and abdominal symptoms. These results are attributed to the fact that lafutidine has strong, continuous antisecretory activity, unaffected by CYP2C19 polymorphisms.

Absolute bioavailability and metabolism of omeprazole in relation to CYP2C19 genotypes following single intravenous and oral administrations

OBJECTIVE

The aim of this study was to evaluate the absolute bioavailability and the metabolism of omeprazole following single intravenous and oral administrations to healthy subjects in relation to CYP2C19 genotypes.

METHODS

Twenty subjects, of whom 6 were homozygous extensive metabolizers (hmEMs), 8 were heterozygous EMs (htEMs) and 6 were poor metabolizers (PMs) for CYP2C19, were enrolled in this study. Each subject received either a single omeprazole 20 mg intravenous dose (IV) or 40 mg oral dose (PO) in a randomized fashion during 2 different phases.

RESULTS

Mean omeprazole AUC (0,infinity) was 1164, 3093 and 10511 ng h/mL after PO, and 1435, 2495 and 6222 ng h/mL after IV in hmEMs, htEMs and PMs, respectively. Therefore, the absolute bioavailability of omeprazole in PMs was significantly higher than that in hmEMs (p < 0.001) and htEMs (p < 0.001). Hydroxylation metabolic indexes after IV and PO were significantly lower in PMs than in hmEMs (p < 0.001) and htEMs (p < 0.001), and was correlated with the absolute bioavailability (p < 0.0001 for both IV and PO). Sulfoxidation metabolic index after IV was significantly different between the CYP2C19 genotypes, whereas no difference was found after a single oral dose.

CONCLUSION

This study indicates that the absolute bioavailability of omeprazole differs among the three different CYP2C19 genotypes after a single dose of omeprazole orally or intravenously. Hydroxylation metabolic index of omeprazole may be mainly attributable to the genotype of CYP2C19. As for the sulfoxidation metabolic index after a single oral dose, intestinal CYP3A may be contributed to omeprazole metabolism.

Development and evaluation of a novel floating in situ gelling system of amoxicillin for eradication of Helicobacter pylori

The aim of this study was to develop a new intra-gastric floating in situ gelling system for controlled delivery of amoxicillin for the treatment of peptic ulcer disease caused by Helicobacter pylori (H. pylori). Gellan based amoxicillin floating in situ gelling systems (AFIG) were prepared by dissolving varying concentrations of gellan gum in deionized water containing sodium citrate, to which varying concentrations of drug and calcium carbonate, as gas-forming agent, was added and dissolved by stirring. The formulation variables like concentration of gellan gum and calcium carbonate significantly affected the in vitro drug release from the prepared AFIG. The in vivo H. pylori clearance efficacy of prepared AFIG in reference to amoxicillin suspension following repeated oral administration to H. pylori infected Mongolian gerbils was examined by polymerase chain reaction (PCR) technique and by a microbial culture method. AFIG showed a significant anti-H. pylori effect in the in vivo gerbil model. It was noted that the required amount of amoxicillin for eradication of H. pylori was 10 times less in AFIG than from the corresponding amoxicillin suspension. The results further substantiated that the prepared AFIG has feasibility of forming rigid gels in the gastric environment and eradicated H. pylori from the gastrointestinal tract more effectively than amoxicillin suspension because of the prolonged gastrointestinal residence time of the formulation.

Clinical trial evaluating amoxicillin and clarithromycin hydrogels (Chitosan-polyacrylic acid polyionic complex) for H. pylori eradication

AIM

It has been suggested that enhancement of amoxicillin or clarithromycin concentration at the gastric tissue may improve the anti-Helicobacter pylori effect of these drugs. This could be achieved by allowing the drug to remain longer in the stomach using dried hydrogels. Our aim was to evaluate the efficacy of an H. pylori eradication regimen including both amoxicillin and clarithromycin hydrogels.

DESIGN

prospective clinical trial.

PATIENTS

with peptic ulcer or functional dyspepsia.

INTERVENTION

7-day rabeprazole-amoxicillin-clarithromycin regimen. In addition, amoxicillin and clarithromycin hydrogels were administered twice daily during the 7 days. The polyionic complex hydrogel was prepared with Chitosan and polyacrylic acid.

OUTCOME

H. pylori eradication was defined as a negative C-urea breath test 8 weeks after completing therapy.

RESULTS

Forty patients were included. One patient did not return for follow-up. Ninety percent of the patients took all the medications correctly. Per-protocol and intention-to-treat eradication rates were 74% (95% CI=58%-86%) and 70% (55%-82%). Mild adverse effects were reported in 4 (10%) patients (diarrhea in 3, and nausea/heartburn in 1).

CONCLUSIONS

Although dried polyionic complexes could serve as suitable candidates for amoxicillin and clarithromycin site-specific delivery in the stomach, its addition does not increase the eradication efficacy of the generally prescribed proton pump inhibitor plus amoxicillin and clarithromycin regimen.

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.

Sofalcone, a mucoprotective agent, increases the cure rate of Helicobacter pylori infection when combined with rabeprazole, amoxicillin and clarithromycin

AIM: The mucoprotective agents, sofalcone and polaprezinc have anti-Helicobacter pylori (H pylori) activities. We determined the therapeutic effects of sofalcone and polaprezinc when combined with rabeprazole, amoxicillin and clarithromycin for Helicobacter pylori infection.

METHODS: One hundred and sixty-five consecutive outpatients with peptic ulcer and H pylori infection were randomly assigned to one of the following three groups and medicated for 7 d. Group A: triple therapy with rabeprazole (10 mg twice daily), clarithromycin (200 mg twice daily) and amoxicillin (750 mg twice daily). Group B: sofalcone (100 mg thrice daily) plus the triple therapy. Group C: polaprezinc (150 mg twice daily) plus the triple therapy. Eradication was considered successful if 13C-urea breath test was negative at least 4 wk after cessation of eradication regimens or successive famotidine in the cases of active peptic ulcer.

RESULTS: On intention-to-treat basis, H pylori cure was achieved in 43 of 55 (78.2%) patients, 47 of 54 (87.0%) and 45 of 56 (80.4%) for the groups A, B and C respectively. Using per protocol analysis, the eradication rates were 81.1% (43/53), 94.0% (47/50) and 84.9% (45/53) respectively. There was a significant difference in the cure rates between group A and B. Adverse events occurred in 10, 12 and 11 patients, from groups A, B and C respectively, but the events were generally mild.

CONCLUSION: The addition of sofalcone, but not polaprezinc, significantly increased the cure rate of H pylori infection when combined with the rabeprazole-amoxicillin-clarithromycin regimen.

Biopsy specimen acquisition in patients with newly diagnosed peptic ulcer disease as determined from a national endoscopic database

BACKGROUND

Eradication of Helicobacter pylori infection decreases peptic ulcer recurrence. Therefore, assessment of Helicobacter pylori status is recommended for patients with newly diagnosed peptic ulcer disease.

METHODS

Data obtained from the Clinical Outcomes Research Initiative's national endoscopic database were analyzed to characterize the acquisition of biopsy specimens in patients with a non-bleeding gastric or duodenal ulcer newly diagnosed by EGD.

RESULTS

Between January 2000 and June 2003, 8299 patients underwent EGD with identification of non-bleeding peptic ulcer disease in the stomach (5390) or the duodenum (2909). Overall, biopsy specimens were obtained from the gastric or duodenal ulcer in 5578 (67%) of these patients. Multivariate analysis identified male gender (odds ratio [OR] 0.75, 95% confidence interval (CI) [0.66-0.85] vs. female), age greater than 75 years (OR 0.67, 95% CI [0.57-0.77] vs. age <55 years), ulcer location (OR 0.53, 95% CI [0.48-0.59] for duodenal vs. gastric ulcers) and endoscopy setting (OR 0.35, 95% CI [0.31-0.39] for academic vs. community; OR 0.36, 95% CI [0.32-0.41] for Veterans Affairs medical centers vs. community) as independent predictors for the acquisition of biopsy specimens (p < 0.001 for all).

CONCLUSIONS

The findings of this study suggest that there is variation in the rates of biopsy specimen acquisition among patients with ulcers who may be at risk for Helicobacter pylori infection. Given the established benefit of Helicobacter pylori eradication, further study is needed to determine whether physicians are diagnosing and treating Helicobacter pylori infection adequately in patients with peptic ulcer.

Low eradication rate of Helicobacter pylori with triple 7-14 days and quadriple therapy in Turkey

AIM: The eradication rate of Helicobacter pylori (H pylori) shows variation among countries and regimens of treatment. We aimed to study the eradication rates of different regimens in our region and some factors affecting the rate of eradication.

METHODS: One hundred and sixty-four H pylori positive patients (68 males, 96 females; mean age: 48 ± 12 years) with duodenal or gastric ulcer without a smoking history were included in the study. The patients were divided into three groups according to the treatment regimens. Omeprazole 20 mg, clarithromycin 500 mg, amoxicillin 1 g were given twice daily for 1 week (Group I) and 2 weeks (Group II). Patients in Group III received bismuth subsitrate 300 mg, tetracyline 500 mg and metronidazole 500 mg four times daily in addition to Omeprazole 20 mg twice daily. Two biopsies each before and after treatment were obtained from antrum and corpus, and histopathologically evaluated. Eradication was assumed to be successful if no H pylorus was detected from four biopsy specimens taken after treatment. The effects of factors like age, sex, H pylori density on antrum and corpus before treatment, the total H pylori density, and the inflammation scores on the rate of H pylori eradication were evaluated.

RESULTS: The overall eradication rate was 42%. The rates in groups II and III were statistically higher than that in group I (P < 0.05). The rates of eradication were 24.5%, 40.7% and 61.5% in groups I, II and III, respectively. The eradication rate was negatively related to either corpus H pylori density or total H pylori density (P < 0.05). The median age was older in the group in which the eradication failed in comparison to that with successful eradication (55 yr vs 39 yr, P < 0.001). No correlation between sex and H pylori eradication was found.

CONCLUSION: Our rates of eradication were significantly lower when compared to those reported in literature. We believe that advanced age and high H pylori density are negative predictive factors for the rate of H pylori eradication.

High rates of recurrence and of transient reinfections of Helicobacter pylori in a population with high prevalence of infection

OBJECTIVES

Little is known concerning the magnitude of reinfection versus recrudescence of Helicobacter pylori (H. pylori) infection after eradication treatment. The aims of this study were to determine the magnitude of H. pylori reinfection versus recrudescence, and to identify possible risk factors for reinfection.

METHODS

Children and adults with upper GI symptoms treated at the Centro Médico Nacional Siglo XXI (Instituto Mexicano del Seguro Social, in Mexico City, Mexico) were studied. H. pylori infection was diagnosed with urea breath test (UBT), histology, and culture. Infected patients received triple therapy, and those who became UBT negative 4-6 wk after treatment were considered as eradicated and were included in the study. A cohort of 141 patients in whom the disease was eradicated was monitored for recurrence with UBT at 3, 6, 9, 12, 18, and 24 months. H. pylori was isolated from gastric biopsy samples before treatment and at recurrence and isolates compared by genotyping.

RESULTS

During this period, 32 (22.7%) cases of recurrence were documented the majority occurring during yr 1. In nine of the 32 (28.1%) cases, recurrence was eradicated spontaneously, suggesting these were transient reinfections. Recurrence rates were significantly higher in the subjects 41-60 yr of age than in younger or older subjects. H. pylori isolates from 12 recurrence cases were genotyped; nine (75%) were classified as true reinfection and three as recrudescence.

CONCLUSIONS

In our population, recurrence rate is high in adults and transient reinfection is common. In several cases, reinfection occurred by multiple strains, which suggests that soon after eradication, patients are exposed to multiple sources of reinfection.

Diagnostic methods for Helicobacter pylori detection and eradication

Helicobacter pylori is the principal cause of peptic ulcer disease and an important risk factor for the development of gastric cancer. The efficacy of 1 week triple therapies, which often have eradication rates of>90%, is undermined by poor patient compliance and bacterial antimicrobial resistance. The development of new anti-H. pylori therapies presents enormous challenges to clinical pharmacologists, not only in the identification of novel targets, but also in ensuring adequate drug delivery to the unique gastric mucus niche of H. pylori. Animal models of H. pylori infection have been developed but their clinical validity has yet to be established. Vaccination, to prevent or treat infection, has been demonstrated in animal models, but human studies have not been so encouraging.

A prospective, randomized study of quadruple therapy and high-dose dual therapy for treatment of Helicobacter pylori resistant to both metronidazole and clarithromycin

BACKGROUND AND AIM

Failure of primary anti-H. pylori therapy results in a high rate of antimicrobial resistance. Here, we investigated the efficacy of high-dose dual therapy and quadruple therapy as salvage treatments for eradication of H. pylori resistant to both metronidazole and clarithromycin.

PATIENTS AND METHODS

Patients with at least one treatment failure and infected with H. pylori resistant to both metronidazole and clarithromycin, were randomized to receive either omeprazole 4 x 40 mg and amoxicillin 4 x 750 mg; or omeprazole 2 x 20 mg, bismuthcitrate 4 x 107 mg, metronidazole 4 x 500 mg and tetracycline 4 x 500 mg. Both regimens were given for 14 days. In cases of persistent infection, a cross-over therapy was performed.

RESULTS

Eighty-four patients were randomized. Cure of H. pylori infection was achieved in 31 patients after dual therapy and in 35 patients after quadruple therapy (per protocol: 83.8% (95% CI, 67.9-93.8) and 92.1% (95% CI, 78.6-98.3), respectively (p=0.71); intention to treat: 75.6% (95% CI: 59.7-87.6) and 81.4% (95% CI: 66.6-91.6), respectively (p=0.60)). Cross-over therapy was performed in six of nine patients, four of whom were cured of the infection.

CONCLUSION

Both high-dose dual therapy and quadruple therapy are effective in curing H. pylori infection resistant to both metronidazole and clarithromycin in patients who experienced previous treatment failures.

Effect of different doses of furazolidone with amoxicillin and omeprazole on eradication of Helicobacter pylori

BACKGROUND

Resistance to metronidazole is one of the most common reasons for Helicobacter pylori treatment failure with classic triple therapy. In contrast, the clarithromycin-based regimen is not cost-effective for developing countries. Furazolidone is a very good substitute for metronidazole and clarithromycin, but its many side-effects limit widespread use. The aim of the present study was to assess the efficacy of two different doses of furazolidone in combination with amoxycillin and omeprazole.

METHODS

A total of 123 patients with duodenal ulcer were randomized and received the following medications for two weeks. Group A: furazolidone 2 x 200 mg + amoxycillin 2 x 1 g + omeprazole 2 x 20 mg/day. Group B: furazolidone 2 x 50 mg + amoxycillin 2 x 1 g + omeprazole 2 x 20 mg/day. Control endoscopy was performed after 6 weeks and two biopsy specimens from the antrum and two from the corpus were taken for a urease test and histology. Eradication was concluded if all tests were negative for H. pylori.

RESULTS

In total, 110 patients completed the study. Four patients in group A did not tolerate the regimen on day 8 of therapy and were excluded from the study. Serious complications such as fever, and fatigue and dizziness, which occurred in the beginning of the second week of treatment (days 8-10), were more common in group A than in group B (19%, 15.9% and 14.3%, respectively, in group A vs 0% in group B). The eradication rate by per protocol analysis was significantly higher in group A than in group B (88.9%vs 67.9%, respectively, P = 0.008). However, this difference was low and not statistically significant by intention-to-treat analysis (76.2% in group A and 62.3% in group B, P = 0.09).

CONCLUSION

The regimen with a non-reduced dose of furazolidone in combination with amoxycillin and omeprazole was effective when the patients tolerated the drugs and completed the study.

Lafutidine, a novel histamine H2-receptor antagonist, vs lansoprazole in combination with amoxicillin and clarithromycin for eradication of Helicobacter pylori

BACKGROUND

In contrast to the growing amount of data concerning proton pump inhibitor-based triple therapy for Helicobacter pylori infection, it is still controversial whether proton pump inhibitor can be replaced by H2 receptor antagonist without compromising efficacy. Lafutidine is a novel potent H2 receptor antagonist with gastroprotective activities such as enhancement of gastric mucosal blood flow.

METHODS

122 outpatients with positive cultures and subsequent successful cultivation of H. pylori for antimicrobial susceptibility tests were randomized to receive a 7-day course of either lafutidine (20 mg twice daily) or lansoprazole (30 mg twice daily), plus clarithromycin (200 mg twice daily) and amoxicillin (750 mg twice daily). Eradication was considered successful if the rapid urease test, culture, histology and [13]C-urea breath test were all negative at least 4 weeks after cessation of therapy. Cytochrome p450 2C19 genotype status using polymerase chain reaction-restriction fragment length polymorphism was also studied.

RESULTS

On intention-to-treat basis, H. pylori cure was achieved in 52 of 61 (85.2%) patients and 49 of 61 (80.3%) patients for the lafutidine- and lansoprazole-based therapies, respectively. The predicted 95% confidential intervals for the 4.9% of the difference were -1.8-11.6%. Using per protocol analysis, the eradication rates were 88.2% (52/59) and 84.5% (49/58), respectively. The predicted 95% confidential intervals for the 3.7% of the difference were -2.6-10.0%. Adverse events were observed in five and six patients, from the lafutidine and lansoprazole groups, respectively, but they were generally mild. Genetic predisposition of cytochrome p450 2C19 had no significant influence on treatment outcome in both regimens.

CONCLUSIONS

The lafutidine-clarithromycin-amoxicillin therapy yielded satisfactory results for eradicating H. pylori, which was comparable with those of the lansoprazole-based regimen with the same drug combination.

Real-time quantitative PCR for detection of Helicobacter pylori

Helicobacter pylori is one of the most common chronic infections in humans, in whom it is a key etiological factor in peptic ulcer disease, gastric mucosa-associated lymphoid tissue lymphoma, and gastric adenocarcinoma. Humans are the bacterium's only host. Here we report the development of a real-time quantitative (Q) PCR-based assay to measure ureC gene copy number to detect H. pylori, based on the fact that there is only one copy of the ureC gene per bacterium. Upon optimization of LightCycler Q-PCR conditions, we obtained a standard curve with a linear range (correlation coefficient = 1) across six logs of DNA concentration. We were able to accurately quantify as few as 1,000 bacteria in our assay. Analysis of variance on 15 randomly selected clinical samples showed good reproducibility of this assay. Comparison of Q-PCR results with bacterial culture and histopathological results from an additional 85 clinical biopsy samples showed a significant difference for the presence of H. pylori. Many samples that were negative for H. pylori by culture and histopathology were positive by Q-PCR. Contamination of PCR by H. pylori or H. pylori genetic material could not be ruled out. In summary, we developed a rapid, sensitive, and real-time Q-PCR method for detecting H. pylori. This technique offers a significant improvement over other available methods for detecting H. pylori in clinical and research samples.

Sources of variation of Helicobacter pylori treatment success in adults worldwide: a meta-analysis

BACKGROUND

A vast number of Helicobacter pylori treatment trials have been conducted. Regimens may vary in efficacy in different patient populations.

METHODS

We identified sources of treatment effect variation from 618 treatment groups using weighted cross-classified multi-level meta-regression models. Summary effect estimates were calculated within groups that lacked identified heterogeneity.

RESULTS

Overall, treatment was less successful with shorter treatment duration and dual drug (versus triple or quadruple drug) therapies. For nitroimidazole-based regimens, treatment was less successful in populations with frequent childhood H. pylori infection or metronidazole resistance and more successful in northeastern Asia. Non-nitroimidazole treatments of longer duration and those from less recent reports were most successful. Some one-week regimens--(nitroimidazole/ tetracycline/bismuth, ranitidine bismuth citrate/amoxicillin/clarithromycin, and clarithromycin/amoxicillin/proton pump inhibitor) were highly successful in northeastern Asia regardless of metronidazole resistance. The most successful regimen in populations with both a high prevalence of metrondiazole resistance and frequent infection in children (metronidazole/furazolidone/amoxicillin) eliminated fewer than 70% of infections.

CONCLUSIONS

More effective treatments are needed for most populations of the world where H. pylori infection in children and drug resistance are common. Current treatment guidelines do not coincide with the best treatment regimens identified in this meta-analysis.

Care of the elderly with gastrointestinal problems in family practice

Gastrointestinal problems in older people cause a great amount of anxiety, morbidity and mortality. In general these diseases present for the first time to family practitioners. The management of gastrointestinal problems is more difficult because in an older age group, functional diseases can present in the same way as organic diseases. In addition, family practitioners see a different kind of patient than speciality physicians and may not have immediate access to diagnostic investigations. In this chapter, the role of the family practitioner in screening for gastrointestinal problems in asymptomatic older people is explored. In addition, how they differentiate between organic and non-organic disease and refer appropriately to secondary care is discussed. The role of family practitioners in the on-going maintenance of gastrointestinal diseases and in the management of Helicobacter pylori in community dwelling older people is also considered.

Famotidine versus omeprazole, in combination with amoxycillin and tinidazole, for eradication of Helicobacter pylori infection

BACKGROUND

Eradication regimens combining two antibiotics with a proton pump inhibitor have been studied intensively. In contrast, only a few studies have focused on the possible role of H2-receptor antagonists in eradication therapy. The mechanism involved in the synergy between antibiotics and proton pump inhibitors is still controversial.

OBJECTIVES

To compare the results of two triple-therapy regimens, different only in the antisecretory drugs used, in patients with Helicobacter pylori infection, and to assess the impact of primary resistance to metronidazole on treatment outcome.

METHODS

A total of 120 patients with peptic ulcer and non-ulcer dyspepsia were randomly assigned to a 2-week course of either: famotidine 40 mg twice a day, amoxycillin 1 g twice a day and tinidazole 500 mg twice a day (FAT group; n = 60); or omeprazole 20 mg twice a day, amoxycillin 1 g twice a day and tinidazole 500 mg twice a day (OAT group; n = 60). Upper endoscopy was performed prior to treatment and at least 4 weeks after completion of treatment and discontinuation of the antisecretory therapy. H. pylori status was assessed by a biopsy urease test, histology and culture.

RESULTS

In the intention-to-treat analysis, eradication of H. pylori was achieved in 48 of the 60 patients (80%; 95% confidence interval: 70-90%) in the FAT group, compared to 50 of the 60 patients (83.3%; 95% confidence interval: 74-93%) in the OAT group. In the per protocol analysis, eradication therapy was achieved in 48 out of 53 patients (90.6%; 95% confidence interval: 83-98%) treated with FAT and 50 out of 57 patients (87.7%; 95% confidence interval: 79-96%) treated with OAT (not significant). The primary metronidazole resistance was present in 28.8% of strains. Overall, per protocol eradication rates in strains resistant and susceptible to metronidazole were 83.3% and 91.3% respectively (P > 0.05).

CONCLUSIONS

Two-week courses of either high-dose famotidine or omeprazole, both combined with amoxycillin and tinidazole, are equally effective for eradication of H. pylori infection. In a 2-week triple therapy, metronidazole resistance has no significant impact on eradication rates.

Retreatment of Helicobacter pylori infection after initial treatment failure

OBJECTIVES

Helicobacter pylori treatment regimens fail to cure the infection in at least 10-20% of patients undergoing initial treatment. Retreatment strategies for patients who have failed initial treatment for H. pylori infection remain poorly described.

METHODS

The literature describing the frequency of H. pylori treatment failure and factors leading to failure is reviewed. The role of antibiotic resistance is discussed and clinical studies assessing success rates according to antibiotic resistance are described. Clinical trials evaluating the treatment success rates for a second episode of treatment are discussed.

RESULTS

The literature describing retreatment of failed H. pylori infection remains limited. The existing data support the use of bismuth-based quadruple therapy or ranitidine bismuth citrate (RBC)-based triple therapy as the preferred agents after initial treatment failure.

CONCLUSION

Further studies are needed to better define the optimal second treatment regimen after failed H. pylori treatment.

CYP2C19 genotype related effect of omeprazole on intragastric pH and antimicrobial stability

PURPOSE

A combination of proton pump inhibitors and antimicrobials has been applied as an anti-Helicobacter pylori (H. pylori) therapy. Omeprazole, one of the proton pump inhibitors, is metabolized by CYP2C19. which exhibits genetic polymorphism. It was reported previously that the overall anti-H. pylori efficacy can be related to the CYP2C19 genotype. The main aim of the present study was to obtain a rational explanation for the relationship between the overall anti-H. pylori efficacy and the CYP2C19 genotype.

METHODS

Six healthy volunteers were classified as extensive metabolizers and poor metabolizers, according to their CYP2C19 genotypes. Plasma concentrations and intragastric pH were monitored prior to and until 24 h after the administration of 20 mg omeprazole. The stability of amoxicillin, clarithromycin, and metronidazole was examined using buffer solutions with monitored intragastric pH, and their remaining percentage in the intragastric space was simulated.

RESULTS

The poor metabolizers, classified by the CYP2C19 genotypes, showed the higher effectiveness in anti-H. pylori therapy, via the higher plasma concentration of omeprazole and the higher intragastric pH, and possibly the higher stability of antimicrobials in the higher intragastric pH.

CONCLUSIONS

CYP2C19 genotyping is a very useful method to determine the effective and safe dosage regimen including the selection of the dual and triple therapy in anti-H. pylori therapy.

5-day vs. 7-day triple therapy with rabeprazole, clarithromycin and amoxicillin for Helicobacter pylori eradication

AIM

To determine whether a 5-day regimen with rabeprazole, clarithromycin and amoxicillin (RCA) was as effective as a 7-day regimen.

METHODS

A total of 139 H. pylori-infected patients were randomized to receive either a 5-day or 7-day course of rabeprazole 10 mg b.d., clarithromycin 400 mg b.d. and amoxicillin 750 mg b.d. Eradication was assessed by CLO test, histology and 13C-urea breath test.

RESULTS

On the intention-to-treat basis, eradication rates were 66% (46 out of 70) and 84% (58 out of 69) for the 5- and 7-day regimens, respectively (P < 0.05). Using per protocol analysis, eradication rates were 70% (46 out of 66) and 91% (58 out of 64) for the 5- and 7-day regimens, respectively (P < 0.01). Adverse events, which were observed in 14 patients from each group, caused discontinuation of treatment in only two patients, resulting in excellent compliance.

CONCLUSIONS

Our 5-day regimen of RCA yielded inferior results, whereas the 7-day regimen achieved an eradication rate exceeding 90% on the per protocol basis. Therefore, treatment regimens of less than 7 days for proton pump inhibitor-clarithromycin-amoxicillin therapies cannot be recommended.

Prevalence and risk factors of Helicobacter pylori-negative peptic ulcer: a multicenter study

Peptic ulcer disease (PUD) has been described in the absence of Helicobacter pylori (Hp) infection, suggesting that different factors are involved in its etiopathogenesis. We investigated prevalence and characteristics of Hp-negative (Hp-) PUD in an area of Northern Italy and calculated the rate of Hp-positive (Hp+) patients with PUD in whom Hp might be coincidental and not causal. Four hundred nine consecutive patients with endoscopically diagnosed PUD were enrolled in seven hospitals. Hp infection was assessed by rapid urease test and histologic examination. The attributable risk percentages in different age groups were calculated by appropriate formulas. Of 409 patients, 31 (7.6%) were Hp- (gastric, 8.3%; duodenal, 7.6%). Age, nonsteroidal antiinflammatory drug (NSAID) consumption, and complication rates were significantly higher in Hp-than Hp+ patients with duodenal ulcers (DUs). Of the Hp-patients with DU, 58% did not use NSAIDs. In patients with Hp+ DU, the attributable risk percentage for Hp infection in patients aged <40 years, 40-60 years, or >60 years was 98%, 88%, and 66%, respectively. The prevalence of Hp- PUD was about 8%, mainly unrelated to any known etiologic factor. In about one-third of Hp+ patients with PUD aged over 60 years, Hp infection might be coincidental and not causal.

Helicobacter pylori

Helicobacter pylori infection is a major cause of peptic ulcer disease, and its detection and eradication are now an important part of gastroenterology. Effective regimes are available which will eliminate the organism in about 90% of cases in developed countries.

Helicobacter pylori. One bacterium and a broad spectrum of human disease! An overview

Since the historical rediscovery of gastric spiral Helicobacter pylori in the gastric mucosa of patients with chronic gastritis by Warren and Marshall in 1983, peptic ulcer disease has been largely viewed as being of infectious aetiology. Indeed, there is a strong association between the presence of H. pylori and chronic active gastritis in histology. The bacterium can be isolated in not less than 70% of gastric and in over 90% of duodenal ulcer patients. Eradication of the organism has been associated with histologic improvement of gastritis, lower relapse rate and less risk of bleeding from duodenal ulcer. The bacterium possesses several virulence factors enabling it to survive the strong acid milieu inside the stomach and possibly damaging host tissues. The sequence of events by which the bacterium might cause gastric or duodenal ulcer is still not fully elucidated and Koch's postulates have never been fulfilled. In the majority of individuals, H. pylori infection is largely or entirely asymptomatic and there is no convincing data to suggest an increase in the prevalence of peptic ulcer disease among these subjects. An increasingly growing body of literature suggests an association between colonization by H. pylori in the stomach and a risk for developing gastric mucosa-associated lymphoid tissue (MALT), MALT lymphoma, gastric adenocarcinoma and even pancreatic adenocarcinoma. The bacterium has been implicated also in a number of extra-gastrointestinal disorders such as ischaemic heart disease, ischaemic cerebrovascular disease, atherosclerosis, and skin diseases such as rosacea, but a causal role for the bacterium is missing. Eradication of H. pylori thus seems to be a beneficial impact on human health. Various drug regimens are in use to eradicate H. pylori involving the administration of three or four drugs including bismuth compounds, metronidazole, clarithromycin, tetracyclines, amoxycillin, ranitidine, omeprazole for 1-2 weeks. The financial burden, side effects and emergence of drug resistant strains due to an increase in the use in antibiotics for H. pylori eradication therapy need further reconsideration.

Furazolidone versus metronidazole in quadruple therapy for eradication of Helicobacter pylori in duodenal ulcer disease

OBJECTIVE

Furazolidone, an old but cheap antibiotic, was shown to be a good alternative to metronidazole in triple therapy for Helicobacter pylori eradication in areas where metronidazole resistant bacteria are common, but randomized studies are lacking.

AIM

A randomized controlled trial to determine the efficacy and safety of furazolidone compared to metronidazole in classic quadruple therapy for eradication of H. pylori infection in duodenal ulcer patients.

METHODS

Patients with endoscopically proven duodenal ulcer and positive urease test were randomized to receive ranitidine 300 mg, amoxycillin 1000 mg and bismuth subcitrate 240 mg b.d, with either furazolidone 200 mg b.d (RABF), or metronidazole 500 mg b.d. (RABM) for 2 weeks. Compliance and side-effects were monitored and recorded by table diary. H. pylori eradication was assessed at least 4 weeks after the completion of therapy with 14C-urea breath test.

RESULTS

A total of 106 patients were enrolled and 101 (59 male, 42 female, mean age=40 +/- 11 years) completed the study. Endoscopic findings and demographic data were comparable in both groups. Intention-to-treat eradication rates were 75% and 55% (P=0.03) and per protocol eradication rates were 82 and 56% (P=0. 006) in the RABF and RABM groups, respectively. Side-effects were reported by 13 patients (27%) in the RABF group (one stopped treatment) compared to five patients (10%) in the RABM group (P=0. 04).

CONCLUSION

Quadruple therapy containing furazolidone, instead of metronidazole, results in a significantly higher H. pylori eradication rate in Iranian duodenal ulcer patients.

Pantoprazole, amoxycillin and either azithromycin or clarithromycin for eradication of Helicobacter pylori in duodenal ulcer

BACKGROUND

Studies have shown that 1-week triple therapy consisting of a proton pump inhibitor, amoxycillin and clarithromycin may cure Helicobacter pylori infection in the majority of patients.

AIM

To establish whether pantoprazole plus amoxycillin in association with either azithromycin or clarithromycin is useful in curing H. pylori infection in patients with a duodenal ulcer.

METHODS

One hundred and ten patients with active duodenal ulcers and H. pylori infection were treated with pantoprazole (days 1-7, 40 mg b.d.; days 8-28 40 mg o.d.) plus amoxycillin 1 g b.d. for the first 7 days. Patients were randomly assigned to receive either azithromycin 500 mg o.d. for the first 6 days (PAAz group; n=55) or clarithromycin 500 mg b.d. for the first 7 days of treatment (PAC group; n=55). H. pylori status was determined by urease test and histology before the treatment, and again 4 weeks after cessation of any medication.

RESULTS

One hundred and three patients completed the study. H. pylori infection was eradicated in 78% (39/50) of patients in the PAAz group (ITT analysis: 71%, 95% CI: 61-83%) vs. 81% (43/53) of patients in the PAC group (ITT analysis: 78%, 95% CI: 69-90%) (N.S.). All ulcers had healed.

CONCLUSION

Our study shows that 1-week triple therapy with pantoprazole, amoxycillin and either azithromycin or clarithromycin is not satisfactory (<80% ITT H. pylori eradication rate).

Emerging and re-emerging infectious diseases

Microbial pathogens discovered as aetiological agents of human disease over the last 25 years are reviewed. Strengthening of laboratory and public health surveillance is of paramount importance for early detection and management of emerging infectious diseases.

Comparative treatment of Helicobacter pylori-positive duodenal ulcer using pantoprazole at low and high doses versus omeprazole in triple therapy

BACKGROUND

Helicobacter pylori eradication has become the standard treatment for peptic ulcer disease. H. pylori-eradicating triple therapy with omeprazole plus two antibiotics has been used until recently; however, the efficacy of pantoprazole and antibiotics for H. pylori eradication has not been researched thoroughly until now. The aim of this randomized clinical trial was to verify the efficacy of triple oral therapy comparing the effects of pantoprazole using two different doses versus omeprazole twice daily in H. pylori eradication, in ulcer healing and relapses, and in gastritis improvement.

MATERIALS AND METHODS

We enrolled 243 patients with H. pylori-positive duodenal ulcer and randomized them into three treatment groups: 84 patients (group Ome40) were assigned to receive omeprazole, 20 mg twice daily, plus amoxicillin, 1 gm twice daily, and clarithromycin, 500 mg twice daily for 10 days; 79 patients (group Pan40) were treated with pantoprazole, 40 mg daily, plus amoxicillin and clarithromycin at the same doses as those of group Ome40; and 80 patients (group Pan80) were treated with pantoprazole, 40 mg twice daily, plus amoxicillin and clarithromycin at the same doses as those of group Ome40.

RESULTS

Ulcer healing was observed in 81 of 84 patients (96.4%) in group Ome40; in 66 of 79 patients (83.5%) in group Pan40; and in 77 of 80 patients (96.2%) in group Pan80. H. pylori was eradicated in 79 of 84 patients (94%) in group Ome40; in 63 of 79 patients (79.7%) in group Pan40; and in 75 of 80 patients (93.7%) in group Pan80.

CONCLUSIONS

We found that 10-day triple therapy with amoxicillin, clarithromycin, and either pantoprazole, 80 mg daily, or omeprazole, 40 mg daily, is highly effective in ulcer healing and is very well tolerated, achieving the 90% cure recommended for an ideal first-line anti-H. pylori positive duodenal ulcer treatment regimen.

Short-term triple therapy with lansoprazole 30 mg or 60 mg, amoxycillin and clarithromycin to eradicate Helicobacter pylori

BACKGROUND

We investigated the efficacy of 30 vs. 60 mg lansoprazole daily in a 1-week triple therapy for eradication of Helicobacter pylori in a prospective randomized study.

METHODS

Two hundred and fifteen consecutive out-patients with peptic ulcer disease or non-ulcer dyspepsia, in whom H. pylori infection was confirmed by histology and/or a urease biopsy test, were randomly assigned to a 1-week treatment with either 15 mg lansoprazole b.d. (LAC15 group) or 30 mg lansoprazole b.d. (LAC30 group) in combination with 1 g amoxycillin b.d. and 500 mg clarithromycin b.d.

RESULTS

Eradication of H. pylori was successful in 87% (per protocol) and 82% (intention-to-treat) of the patients with LAC15 and in 94% (per protocol) and 87% (intention-to-treat) of the patients with LAC30. The difference was not significant. In both treatment groups, all peptic ulcers were healed at the check-up. Adverse effects were seen in 11 patients of the LAC15 group and 10 patients of the LAC30 group: they caused discontinuation of the therapy in four of the LAC15 group and two patients of the LAC 30 group.

CONCLUSIONS

A 7-day triple therapy using lansoprazole (LAC15) is an efficient and economical regimen for the eradication of H. pylori.

Head-to-head comparison of 1-week triple regimens combining ranitidine or omeprazole with two antibiotics to eradicate Helicobacter pylori

BACKGROUND

Triple therapies containing omeprazole and ranitidine have been shown to be equivalent in eradicating H. pylori infection, but have been assessed either separately or head-to-head, only in small trials.

AIM

To carry out a large randomized controlled study comparing omeprazole and ranitidine combined with two antibiotic combinations for 1 week.

METHODS

Three hundred and twenty H. pylori-positive patients were randomly subdivided into four equal-sized groups and received one of the following treatments: OAM = omeprazole 20 mg b.d. + amoxycillin 1 g b.d. + metronidazole 500 mg b.d.; RAM = ranitidine 300 mg b.d. + amoxycillin 1 g b.d. + metronidazole 500 mg b.d.; OAC = omeprazole 20 mg b.d. + amoxycillin 1 g b.d. + clarithromycin 250 mg t.d.s.; RAC = ranitidine 300 mg b.d. + amoxycillin 1 g b.d. + clarithromycin 250 mg t.d.s. The assessment of H. pylori status was performed before and 4 weeks after the end of therapy by means of CLO-test and histology. H. pylori infection was considered to be eradicated when both tests were negative.

RESULTS

OAM and RAM eradicated H. pylori in 89% and 85% of cases on per protocol (P = 0.48) and in 77% and 75% of cases on intention-to-treat analyses (P = 0.71). OAC and RAC eradicated H. pylori in 67% and 70% of cases on per protocol (P = 0.68) and in 57% and 64% of cases on intention-to-treat analyses (P = 0.41). In contrast, there was significant difference between OAM and OAC (P<0.01) and between RAM and RAC (P<0.05). Side-effects occurred in 15%, 10%, 17% and 16% of patients with respect to the above four subgroups.

CONCLUSIONS

Omeprazole and ranitidine combined with two antibiotics for 1 week are equally effective in the eradication of H. pylori infection, and these results question the role of profound acid suppression in the eradication of the bacterium.

Treatment options for Helicobacter pylori infection when proton pump inhibitor-based triple therapy fails in clinical practice

BACKGROUND

The effectiveness of Helicobacter pylori eradication regimens has not been extensively investigated in the clinical practice setting. The optimal treatment choice after an initial failed eradication attempt has not been determined.

AIMS

To evaluate proton pump inhibitor-based triple therapies as first-line eradication regimens in clinical practice, and to establish the efficacy of second-line regimens in the context of an initial failed eradication attempt.

METHODS

Three hundred and eight patients with dyspepsia and evidence of H. pylori at endoscopy were recruited. As first-line therapy, 116 patients received omeprazole 20 mg b.d. in combination with amoxycillin 1 g b.d. and clarithromycin 500 mg b.d. (OAC) while 192 patients received omeprazole 20 mg b.d. in combination with metronidazole 400 mg b.d. and clarithromycin 250 mg b.d. (OMC). H. pylori status was reassessed at least 4 weeks after therapy (25 patients failed to attend for further testing). Of 52 patients with an initial failed eradication attempt, 20 patients received a 1 week quadruple therapy regimen incorporating omeprazole 20 mg b.d., tripotassium dicitrato bismuthate 120 mg q.d.s., tetracycline 500 mg q.d.s. and metronidazole 400 mg t.d.s., 20 patients received a 2-week proton pump inhibitor-based triple therapy regimen as described, and 12 patients received a further 1-week proton pump inhibitor-based triple therapy regimen.

RESULTS

Including 308 patients, the intention-to-treat (ITT) eradication rates for OAC and OMC as first-line regimens were 72% (95% CI: 63-80%) and 73% (95% CI: 67-79%) respectively. A per protocol (PP) analysis on the 283 patients who completed follow-up gives an initial eradication rate of 78% (95% CI: 69-86%) for OAC and 79% (95% CI: 73-85%) for OMC. There were 60 patients (21%; 95% CI: 17-26%) in whom the initial eradication attempt was unsuccessful. With second-line therapy, H. pylori was successfully eradicated in a further 35/52 (67%; 95% CI: 58-73%) patients. The eradication rates with the quadruple regimen and 2-week triple therapy regimens were 75% (95% CI: 56-94%) and 80% (95% CI: 63-98%) respectively (P = 0. 71). The eradication rate with a repeat 1-week regimen was 33% (95% CI: 7-60%).

CONCLUSIONS

The eradication rates achieved in this 'in practice' study with recommended first-line 1-week proton pump inhibitor-based triple therapy regimens were lower than the rates achieved with similar regimens in the clinical trial setting. A repeat 1-week proton pump inhibitor-based triple therapy regimen was not successful as a salvage therapy. Both the 2-week proton pump inhibitor-based triple therapy regimen and the 1-week quadruple therapy regimen were successful second-line treatments in >/=75% of patients.

An evaluative system for the response of antibacterial therapy: based on the morphological change of Helicobacter pylori and mucosal inflammation

The diagnostic standard is an important factor in the evaluation of the antibacterial effect to Helicobacter pylori (H. pylori). Few studies have evaluated the bacterial morphological change. In the present study, H. pylori was examined by means of electron microscopy (EM), light microscopy (LM) and immunohistochemical staining. Patients were followed up from 6 weeks to more than 1 year after treatment for H. pylori, and the results of the 13C-urea breath test (UBT) were compared. A '4-L' evaluative system was used for histological diagnosis; that is, complete, significant, partial and negative response for H. pylori treatment. Complete response showed no H. pylori in histology, and positive 13C-UBT and negative response showed positive in both diagnoses. A significant response showed the morphology of H. pylori was thick walled by EM, that there was no obvious active inflammation, and was negative for C-UBT. These H. pylori showed a coccoid form and possibly static bacteria, which was resistant to further antibacterial therapy. The '4-L' system could evaluate the antibacterial effect, suggesting the necessity for a second line of therapy for H. pylori. It is suggested that this sensitive evaluative system is suitable for clinical applications for antibacterial therapy.

High dose omeprazole plus amoxicillin and azithromycin in eradication of Helicobacter pylori in duodenal ulcers

BACKGROUND

The aim of our study was to establish whether one-week triple therapy regimen (omeprazole, amoxicillin, azithromycin) with low dose (2 x 20 mg/day) or high dose omeprazole (2 x 40 mg/day) is more effective in curing H. pylori infection in patients with active duodenal ulcer disease.

METHODS

One hundred and twenty patients with duodenal ulcer and H. pylori infection were treated with amoxicillin 2 x 1000 mg/day for the first 7 days plus azithromycin 500 mg/day for the first 6 days. Patients were randomly assigned to receive either omeprazole 2 x 20 mg/day for the first 7 days (group A; n = 60) or omeprazole 2 x 40 mg/day for the first 7 days (group B; n = 60). After 7 days all patients in both groups continued treatment with omeprazole (40 mg/day (days 8-14) and 20 mg/day (days 15-28)). H. pylori status was determined by urease test and histology before the treatment and 4 weeks after cessation of any medication.

RESULTS

One hundred and thirteen patients completed the study. H. pylori infection was eradicated in 73.2% [41/56] of patients in group A (intention-to-treat [ITT] analysis: 68.3%; 95% CI: 58.6-80.4%) vs. 82.5% [47/57] of patients in group B (ITT analysis: 78.3%; 95% CI: 67.8-87.9%; NS). All ulcers had healed after 4 weeks of omeprazole treatment. Side effects, usually minor, were recorded in 12.5% (group A) and in 14% (group B) of patients (NS), but therapy was discontinued for only one patient in group B (NS).

CONCLUSION

There was no statistically significant difference between one-week triple therapy regimen (omeprazole, amoxicillin, azithromycin) with high dose omeprazole (2 x 40 mg/day) and regimen with low dose omeprazole (2 x 20 mg/day) in curing H. pylori infection in patients with active duodenal ulcer disease.