Treatment of Helicobacter pylori infections

The treatment of Helicobacter pylori (H.p.) infection is based on the recommendations of the Maastricht consensus conference 1996. The main indications for eradication of H.p. are peptic ulcer disease, gastritis with severe histological abnormalities, low grade gastric MALT lymphoma and a history of resection for gastric cancer. The results of recent studies demonstrate that the symptoms of non-ulcer dyspepsia are not improved by H.p. eradication. A family history of gastric cancer and an earlier operation for peptic ulcer are considered advisable indications for the treatment of H.p. infection. Triple therapies consisting of a proton pump inhibitor (PPI) or ranitidine bismuth citrate plus 2 antibiotics are established as effective and well-tolerated first line regimens. The most important antibiotics are clarithromycin and amoxicillin. The efficacy of metronidazole is impaired by an increasing rate of resistant strains. Only few new antibiotics are currently tested in clinical trials. After the failure of a first anti-H.p. treatment it is advisable to change antibiotics according to the probability of resistance, to increase dosage and duration of treatment and to include bismuth compounds in the second line regimen. An alternative option after failed triple therapies may be a high dosage and prolonged dual regimen with a PPI and amoxicillin or quadruple therapy consisting of a PPI, bismuth subcitrate, tetracycline and metronidazole.     

"Best practice' for Helicobacter pylori eradication in the primary care setting

This study determined the relative cost effectiveness of proton pump inhibitor (PPI) based triple therapy regimens for Helicobacter pylori eradication in the primary care setting. Using decision tree analysis the expected cost for each H. pylori eradication strategy was determined from the cost of each treatment option multiplied by the probability of that option occurring. Probabilities were obtained using the GMS prescribing database where all patients who received amoxycillin, clarithromycin and a PPI in the ERHA region in 2002 were followed for one year. Depending on the regimen adopted, 40.8% to 46.1% of patients did not require any further medication in the year following H. pylori eradication treatment. The strategy of rabeprazole, amoxycillin and clarithromycin was the most cost effective option with a cost of Euro466 per asymptomatic patient. Two-way sensitivity analysis indicated that the cost of rabeprazole triple therapy and the duration of rabeprazole maintenance therapy would each have to increase by 30% before this strategy ceased to be the most cost effective and hence best practice option for eradicating Helicobacter pylori in the primary care setting in Ireland.     

Helicobacter pylori & gastric disease

Since the discovery of Helicobacter pylori(H. pylori), causal linkage between H. pylori infection and some of gastric disease has been generally accepted from the results of many studies. Indeed the usefulness of H. pylori eradication therapy for acute gastritis, peptic ulcer, gastric polyp and MALT lymphoma etc. has been reported. In the low grade MALT lymphoma, the regression rate by this therapy is about 70%. On the other hand, we should pay the caution to several adverse effects, such as drug resistance and GERD, of H. pylori eradication therapy. However, based on the several results of comparative studies between antibiotic therapy and the other one, the antibiotic therapy for peptic ulcer is only covered by national health insurance at present. The reversibility of gastric precancerous conditions such as mucosal atrophy, intestinal metaplasia and dysplasia by antibiotic therapy has been studied, but its significance is not clear yet. In animal experiment, H. pylori infection induced gastric adenocarcinoma in Mongolian Gerbils. However, this phenomenon is limited to this kind of animal only. To proof the causal link between H. pylori infection and genesis of gastric cancer in human being, clinical intervention trials are ongoing in the world. If these trials can clarify it, the H. pylori eradication therapy will be established as preventive measure for gastric carcinogenesis.     

Helicobacter pylori and gastroesophageal reflux disease

The latest accessible data indicate, that Helicobacter pylori (H.p.) infection, particularly by cagA-positive strains, protects against the development of gastroesophageal reflux disease (GERD) and its complications. Various epidemiological, pathophysiological and clinical studies demonstrate this protective effect, which is dependent on the extent of H.p. induced gastritis. Severe corpus gastritis may cause a profound reduction of acid secretion. In regard to acute or chronic PPI therapy of GERD the biological antisecretory effect of H.p. is of minor benefit. Development of atrophic gastritis in patients with GERD treated chronically with PPI is still uncertain. On account of the protective effect of H.p. against GERD, it is prudent to reserve H.p. eradication for the well-established indications.     

Efficacy of levofloxacin,amoxicillin and a proton pump inhibitor in the eradication of Helicobacter pylori in Brazilian patients with peptic ulcers

OBJECTIVES:

The eradication of Helicobacter (H.) pylori allows peptic ulcers in patients infected with the bacteria to be cured. Treatment with the classic triple regimen (proton pump inhibitor, amoxicillin and clarithromycin) has shown decreased efficacy due to increased bacterial resistance to clarithromycin. In our country, the eradication rate by intention to treat with this regimen is 83%. In Brazil, a commercially available regimen for bacterial eradication that uses levofloxacin and amoxicillin with lansoprazole is available; however, its efficacy is not known. Considering that such a treatment may be an alternative to the classic regimen, we aimed to verify its efficacy in H. pylori eradication.

METHODS:

Patients with peptic ulcer disease infected with H. pylori who had not received prior treatment were treated with the following regimen: 30 mg lansoprazole bid, 1,000 mg amoxicillin bid and 500 mg levofloxacin, once a day for 7 days.

RESULTS:

A total of 66 patients were evaluated. The patients’ mean age was 52 years, and women comprised 55% of the sample. Duodenal ulcers were present in 50% of cases, and gastric ulcers were present in 30%. The eradication rate was 74% per protocol and 73% by intention to treat. Adverse effects were reported by 49 patients (74%) and were mild to moderate, with a prevalence of diarrhea complaints.

CONCLUSIONS:

Triple therapy comprising lansoprazole, amoxicillin and levofloxacin for 7 days for the eradication of H. pylori in Brazilian peptic ulcer patients showed a lower efficacy than that of the classic triple regimen.     

Antimicrobial susceptibility testing of Helicobacter pylori to selected agents by agar dilution method in Shiraz-Iran

PURPOSE: To assess the pattern of antimicrobial susceptibility profile of Helicobacter pylori isolates from patients with gastritis, duodenal ulcer (DU) and gastroesophageal reflux disease (GERD) residing in Shiraz, Iran. METHODS: One hundred and six H. pylori isolates from patients with gastritis, DU and GERD undergoing endoscopy at our university hospitals and clinics were analysed for their antimicrobial susceptibility to metronidazole, clarithromycin, amoxicillin, co-amoxiclav, tetracycline, ciprofloxacin and furazolidone. The minimum inhibitory concentrations were determined by agar dilution method. RESULTS: Overall H. pylori resistance rate was 72.6% to metronidazole, 9.4% to clarithromycin and furazolidone, 20.8% to amoxicillin and 4.7% to tetracycline and ciprofloxacin. No resistance to co-amoxiclav was detected among H. pylori isolates. No significant differences between antimicrobial resistance and clinical outcome were detected. CONCLUSIONS: With regard to the increasing resistance of H. pylori isolates to various antibiotics, susceptibility testing of H. pylori isolates prior to the treatment of infection must be performed to achieve better eradication and to reduce the risk of selection of H. pylori resistant strains.     

埃索美拉唑治疗消化性溃疡150例疗效观察

目的：观察埃索美拉唑三联疗法治疗幽门螺杆菌（Helicobacter Pylori，简称HP）阳性消化性溃疡的效果。方法：将确诊为HP阳性消化性溃疡150例患者随机分为埃索美拉唑组和奥美拉唑组，每组75例。两组分别给予阿莫西林1g，1日2次，克拉霉素0．5g，1日2次，埃索美拉唑组加用埃索美拉唑20mg，1日2次，奥美拉唑组加用奥美拉唑20mg，1日2次。1周后两组分别单用埃索美拉唑20mg，1日1次，奥美拉唑20mg，1日1次，维持治疗3周。两组患者治疗前和治疗后检测HP状况。结果：埃索美拉唑组溃疡愈合率为93．4％，奥美拉唑组溃疡愈合率为90．7％；埃索美拉唑组HP根除率为93．3％，奥美拉唑组HP根除率为90．6％。两组比较溃疡愈合率及HP根除率差异无统计学意义（P〉0．05）；第1天和第2天腹痛缓解率埃索美拉唑组为34．7％和60．0％，奥美扭唑组为16．0％和36．0％，两组比较差异有统计学意义（P〈0．05）。结论：埃索美拉胜、阿英西林、克拉霉素三联疗法治疗HP感染消化性溃疡优于奥美拉唑、阿莫西林、克拉霉素三联疗法，腹痛缓解较快。     

The history of Helicobacter pylori

Histological and ultrastructural studies of gastric mucosa with spiral bacteria had been published at the Royal Perth Hospital of Western Australia in 1979. The pathologist Warren correlated them with inflammation. In 1981, Marshall was training in internal medicine. Warren, Marshall and Goodwin started culture of bacteria, but spiral bacteria were not cultured. The 35th culture was left during the Easter holiday, and after 5 days 1-mm transparent colonies were seen on the plate. Since discovery Helicobacter pylori(H. pylori) have continued to fascinate and challenge doctors and scientists for 18 years to come. In 2000, triple therapy with PPI, Amoxicillin and clarithromycin was approved for treatment of peptic ulcer disease in Japan.     

The cause of failure of eradication treatment of Helicobacter pylori

The drug treatment, the combination of lansoprazole + amoxicillin + clarithromycin, for Helicobacter pylori infection with gastroduodenal ulcer was approved for the national heath insurance November 2000 in JAPAN, and has been widely applied. However, failures of eradication have been counted in 10-20% of the cases. The major reason of the failure has been reported as the drug resistance of the H. pylori. Here, we surveyed the antimicrobial resistance of 70 clinical isolates in a Showa University Hospital 2001, 1 to 2002, 1. As a result, the ratio of primary resistance to amoxicillin was about 1.4%, and clarithromycin was about 11.4%. Among 70 H. pylori positive cases, 14 cases were treated with eradication 3 drug combination therapy. In 5 cases, H. pylori were detected after eradication treatment and these five strains acquired the second resistance to neither amoxicillin nor clarithromycin. To distinguish the cause of H. pylori culture-positive after eradication treatment is whether the failure of eradication itself or re-infection, we attempted the analysis of the restriction pattern of H. pylori genome (genome type) using pulsed-field gel electrophoresis. In all 5 cases, genome types of before and after treatment were identical, suggesting the failure of eradication treatment. Three of 5 cases, isolates before and after treatment were susceptible to both of amoxicillin and clarithromycin. Thus, the reason of failure of eradication is considered to ingestion compliance, not antimicrobial agent resistance nor reinfection. The rest of 2 cases, the primary resistance to clarithromycin may result the failure of eradication. Test for drug susceptibility and genome type analysis of H. pylori are significant in certification of an authenticity of an eradication treatment.     

Efficacy of two triple eradication regimens in children with Helicobacter pylori infection

Triple therapy with bismuth subsalicylate, amoxicillin, metronidazole (BAM) or with omeprazole, amoxicillin, clarithromycin (OAC) has been commonly used for the eradication of Helicobacter pylori infection. We compared the efficacy of these triple therapies in children with H. pylori infection. We retrospectively analyzed results in 233 children with H. pylori infection and treated with OAC (n=141) or BAM (n=92). Overall eradication rates of triple therapy with OAC and BAM were 74% and 85%, respectively, which showed no statistical difference. Our study showed that the triple therapy with BAM was more effective for the first-line eradication of H. pylori infection in Korean children, but has no statistical difference with OAC regimen.     

Meta-Analysis of First-Line Triple Therapy for Helicobacter pylori Eradication in Korea: Is It Time to Change?

Proton pump inhibitor (PPI)-based triple therapy consisting of PPI, amoxicillin, and clarithromycin, is the recommended first-line treatment for Helicobacter pylori infection. However, the eradication rate of triple therapy has declined over the past few decades. We analyzed the eradication rate and adverse events of triple therapy to evaluate current practices in Korea. A comprehensive literature search was performed up to August 2013 of 104 relevant studies comprising 42,124 patients. The overall eradication rate was 74.6% (95% confidence interval [CI], 72.1%-77.2%) by intention-to-treat analysis and 82.0% (95% CI, 80.8%-83.2%) by per-protocol analysis. The eradication rate decreased significantly from 1998 to 2013 (P < 0.001 for both intention-to-treat and per-protocol analyses). Adverse events were reported in 41 studies with 8,018 subjects with an overall incidence rate of 20.4% (95% CI, 19.6%-21.3%). The available data suggest that the effectiveness of standard triple therapy for H. pylori eradication has decreased to an unacceptable level. A novel therapeutic strategy is warranted to improve the effectiveness of first-line treatment for H. pylori infection in Korea.

Graphical Abstract

相似文献   

Eradication of Helicobacter pylori in clinical situations

Helicobacter pylori is prevalent worldwide, especially in developing countries, and is associated with several upper gastrointestinal diseases. Since it is present in over 90% of duodenal ulcer patients, empirical eradication in these patients is often recommended. In gastric ulcer patients, eradication is indicated only after the infection is confirmed. Testing for H. pylori infection should be carried out in patients with peptic ulcer hemorrhage, because eradication has been shown to reduce recurrent bleeding. Both H. pylori and NSAIDs are risk factors for peptic ulceration, and it is reasonable to screen for and eradicate H. pylori infection in peptic ulcer patients taking NSAIDs. H. pylori is a group I carcinogen for gastric adenocarcinoma, and should be eradicated for the primary prevention of this cancer. Eradication of this organism has been reported to result in regression of early low-grade mucosa-associated lymphoid tissue lymphoma. The role of H. pylori infection in the causation of gastroesophageal reflux and non-ulcer dyspepsia is not clearly established. Several tests are available for the diagnosis of H. pylori infection. These include invasive tests, such as histology, culture and urease test, and non-invasive tests, such as serology, urea breath test and stool antigen test. The choice of test is determined by clinical indication, pretest probability of infection, as well as the availability, cost, sensitivity and specificity of the test. H. pylori eradication therapy using proton pump inhibitor with clarithromycin and amoxycillin for 7 days has a success rate of 85-90%. Improved living standard and sanitation are vital in the control of H. pylori transmission and infection. Future development may include the use of vaccines against H. pylori, and therapies specifically targeting cagA strains of the bacteria.     

Alterations in antral cytokine gene expression in peptic ulcer patients during ulcer healing and after Helicobacter pylori eradication

Earlier studies have shown that the antral immune response in Helicobacter pylori infection has a mixed Th1-Th2-T- regulatory profile. After eradication, a chronic inflammation remains in some patients, but a follow-up study with a comprehensive cytokine profile in has not previously been published. Twelve patients with H. pylori positive peptic ulcer disease (five antral and seven duodenal) were enrolled and cytokine gene expressions in antral biopsies were determined (1) at entry, (2) after resolving the ulcer with proton pump inhibitor (PPI) treatment and (3) after eradication. The second endoscopy was performed 4 weeks after ending the PPI treatment, and the third endoscopy was performed after a mean of 10 months after eradication. Inflammation was graded according to the updated Sydney system. Interleukin (IL)1β, IL8, IL12A, IL18, TNFα, IFNγ, IL4, IL6 and IL10 expression levels were analysed by real-time RT-PCR. Mixed mononuclear and neutrophil infiltrates were seen at entry and after ulcer healing. After eradication, low-grade mononuclear infiltrates were found. The cytokine expression levels after ulcer healing ( H. pylori positive gastritis) were not significantly different from the levels at entry (ulcer). After eradication, attenuation of the Th1 cytokines except for TNFα and a persisting increase of IL4 levels were observed, whereas the IL10 expression was markedly reduced. The present data did not indicate a specific ulcer promoting cytokine gene regulation profile. However, after eradication a chronic low-grade inflammation was seen with reduced Th1, prolonged Th2 and disappearance of the T- regulatory response.     

四联疗法治疗幽门螺旋杆菌相关性十二指肠球炎疗效分析

目的 比较标准四联与三联法治疗幽门螺旋杆菌相关性十二指肠球炎临床疗效。方法 选择2017年5月~2018年5月我院收治的幽门螺旋杆菌相关性十二指肠球炎患者96例,随机分为观察组和对照组,每组48例。观察组采用兰索拉唑、克拉霉素、阿莫西林、果胶铋标准四联治疗,对照组采用兰索拉唑、克拉霉素、阿莫西林标准三联治疗。比较两组患者Hp根除率、复发率及不良反应情况。结果 观察组患者Hp根除率为91.67%,高于对照组75.00%,差异具有统计学意义（P＜0.05）。观察组患者Hp复发率为10.42%,低于对照组的20.83%,差异具有统计学意义（P＜0.05）。观察组不良反应发生率为4.16%,低于对照组的6.25%,但组间比较,差异无统计学意义（P＞0.05）。结论 标准四联疗法治疗幽门螺旋杆菌相关性十二指肠球炎,Hp根除率较高,复发率低,且不增加不良反应发生率。     

Antibiotic susceptibility patterns of Helicobacter pylori and triple therapy in a high-prevalence area

This study aims to determine primary Helicobacter pylori resistance and its effect on eradication of the organism. Ninety-two patients with dyspeptic symptoms were enrolled. H. pylori was cultured and antibiotic sensitivity was determined by the Epsilometer test (Etest) for clarithromycin (CLR), amoxicillin (AMX) and metronidazole (MTR). 23S ribosomal RNA (rRNA) point mutations associated with clarithromycin resistance were also detected. Patients were treated with omeprazole (40 mg daily), CLR (500 mg) and AMX (1g twice a day) for 14 days. A 14C-urea breath test (14C-UBT) was repeated four weeks after completion of treatment to confirm eradication. Triple therapy failure was seen in 30 (33%) patients. The resistance rates were: CLR 33% (30/92), MTR 48% (44/92) and AMX 2% (2/92). Clarithromycin resistance (CLR-R) was present in the 16-39 age group in 21 (47%) (P = 0.007) compared to nine (19%) in the 40-79 age group. CLR resistance was seen in 30 H. pylori isolates, 20 (67%) from patients with non-ulcer dyspepsia (NUD), six (20%) with gastric ulcer (GU) and four (13%) with duodenal ulcer (DU). Triple therapy failure was associated with CLR-R in 28 (93%) (P < 0.001). CLR-R mutations were present in 30 (33%) and were associated with treatment failure in 27 (90%; P < 0.001). They were present in 20 (44%) isolates obtained from patients in the 16-39 age group (P = 0.018). Treatment failure was associated with A2142G mutation in 20 (67%; P < 0.001), A2143G mutation in 12 (40%; P < 0.001) and A2142C mutation in five (17%; P = 0.003). In conclusion, triple therapy failure was associated with CLR-R. Metronidazole resistance exceeded that of CLR, hence it cannot be substituted for CLR in a triple therapy.     

Relationship between Helicobacter pylori and rosacea: it may be a myth

Although it is debatable whether Helicobacter pylori may play a role in the pathogenesis of rosacea, some authors suggested that the treatment of H. pylori might have a beneficial effect. The aim of this investigation was to compare the prevalence of H. pylori between rosacea patients and controls, and to evaluate an effect of H. pylori eradication on rosecea by a 2-week triple therapy that was composed of amoxicillin, clarithromycin and omeprazole. H. pylori was detected by using gastroscopic biopsy with Warthin-Starry stain. Forty-two (84%) of 50 patients with rosacea and 39 (78%) of 50 controls had H. pylori, showing no significant difference in prevalence. The cure rates of H. pylori in rosacea patients and controls were 80% (16/20) and 85% (17/20), respectively. There was no significant decrease in the intensity of erythema in active treatment and placebo groups both during and after the treatment. Temporary improvement in papulopustules exclusively during the treatment (within 2 weeks) could be independent of H. pylori eradication. Overall, no significant reduction in the number of papulopustules was observed in active treatment and placebo groups after the treatment (in 2 months). Taken together, our study found no significant lessening of rosacea lesions by treating H. pylori infection, which conclusively does not concur with a view that H. pylori may be related to rosacea.     

RAPD分析在Hp菌株鉴定中的应用

目的建立一种快速准确地鉴定不同幽门螺杆菌（Ｈｐ）菌株的ＲＡＰＤ分析方法，并评价它在区分Ｈｐ复发和再感染中的应用价值。方法用苯酚－氯仿方法提取ＨｐＤＮＡ，以一个１０ｎｔ的寡核苷酸引物，建立ＨｐＰＣＲ扩增体系，所得ＰＣＲ产物以２％琼脂糖凝胶电泳分析（ＲＡＰＤ分析）。同一菌株验证方法的重复性，对４例十二指肠溃疡伴Ｈｐ感染者三联治疗前后及根除后一年内再现的Ｈｐ菌株进行ＲＡＰＤ分析，鉴别复发和再感染。结果（１）同一Ｈｐ菌株于不同时间进行的２次ＲＡＰＤ分析，所得的ＰＣＲ产物完全一致，说明该方法具有良好的可重复性。（２）５０株不同的Ｈｐ菌株各产生不同的ＲＡＰＤ图谱，可按此图谱的不同将它们区分开来。（３）对４例十二指肠溃疡伴Ｈｐ感染治疗前及治疗后１年再现的菌株的ＲＡＰＤ分析，发现３例患者的菌株具有相同的ＲＡＰＤ图谱，证实为原菌株的复发，而１例患者的菌株则产生不同的ＲＡＰＤ图谱，推测为新菌株的再感染，４例患者随访１年均为十二指肠溃疡复发。结论ＲＡＰＤ分析只需单一的随机引物，方法简单、快速、经济、重复性好，可用于区分不同来源的Ｈｐ菌株，特别对治疗前后再现的菌株复发和再感染的鉴别更具临床应用价值     

Efficacy of levofloxacin and rifaximin based quadruple therapy in Helicobacter pylori associated gastroduodenal disease: a double-blind, randomized controlled trial

The aim of this study was to evaluate the efficacy of levofloxacin and rifaximin based quadruple regimen as first-line treatment for Helicobacter pylori infection. A prospectively randomized, double-blinded, parallel group, comparative study was performed. Three hundred consecutive H. pylori positive patients were randomized to receive: omeprazole, amoxicillin, clarithromycin (OAC); omeprazole, amoxicillin, levofloxacin (OAL); and omeprazole, amoxicillin, levofloxacin, rifaximin (OAL-R). The eradication rates in the intention to treat (ITT) and per protocol (PP) analyses were: OAC, 77.8% and 85.6%; OAL, 65.3% and 73.6%; and OAL-R, 74.5% and 80.2%. The eradication rate achieved with OAC was higher than with OAL on the ITT (P = 0.05) and PP analysis (P = 0.04). OAL-R regimen was not inferior to OAC. The frequency of moderate to severe adverse effects was significantly higher in OAC treatment group. Especially, diarrhea was most common complaint, and there was a significantly low rate of moderate to severe diarrhea with the rifaximin containing regimen. In conclusion, the levofloxacin and rifaximin based regimen comes up to the standard triple therapy, but has a limited efficacy in a Korean cohort. The rifaximin containing regimen has a very high safety profile for H. pylori eradication therapy.     

The role of screening for Helicobacter pylori in patients with duodenal ulceration in the primary health care setting.

BACKGROUND: It is known that at least 90% of duodenal ulcers are caused by infection with the bacterium Helicobacter pylori. Eradicating this organism usually results in complete resolution of the disease. Testing for H pylori was introduced relatively recently, and thus, many patients known to have uncomplicated peptic ulcer disease who continue to need long-term treatment with ulcer-healing drugs have never been tested for the infection or offered eradication therapy. In modern computerized practices, this subgroup of patients can readily be identified by reference to morbidity and repeat prescribing data. Eradication of H pylori infection in this group of patients has great potential benefit for the individuals concerned as well as cost-saving benefit for the National Health Service. AIM: The aim of this prospective study was to determine whether it is worthwhile screening for and treating H pylori infection in patients in a general practice population with previously diagnosed duodenal ulcer disease taking ulcer-healing drugs long term. METHOD: In 1994, in a practice of 7100 patients, morbidity and repeat prescribing data were used to identify 40 patients (0.6%) with proven duodenal ulcer disease taking ulcer-healing medication long term and with uncertain H pylori status. Twenty-nine of the 40 subjects agreed to undergo serology testing for H pylori antibodies. Of 20 (69%) who were positive, 18 (eight women, median age 63.8 years) were given eradication therapy. Seventeen patients received omeprazole 40 mg once daily and amoxycillin 500 mg three times daily for 14 days with metronidazole 400 mg three times daily for the first 7 days; for the remaining patient metronidazole was inadvertently omitted. [13C]Urea breath testing was carried out at the local hospital at least one month after therapy to determine whether eradication treatment had been successful. Subjects were also personally followed up by telephone after 1 and 4 months to assess the success of treatment subjectively. RESULTS: [13C]Urea breath testing showed that H pylori eradication was successful in all 17 patients (100%) who received the intended eradication regimen. Helicobacter pylori was not eradicated in the patient who received only omeprazole and amoxycillin. Four months after successful H pylori eradication, 13 of the 17 (76%) patients remained completely asymptomatic. Two of the four patients who had some recurrent dyspepsia had known gastro-oesophageal reflux and their ongoing symptoms after eradication therapy seemed, on close questioning, to be more attributable to this than to duodenal ulcer disease. CONCLUSION: Testing for and eradication of H pylori is worthwhile in general practice in those patients with previous proven duodenal ulceration who need long-term ulcer-healing medication. The high rate of eradication of H pylori achieved with the regimen used in this study compares very favourably with that of other treatment regimens. However, in patients with duodenal ulcers there may be coexisting pathology, and H pylori eradication does not necessarily result in complete disappearance of dyspeptic symptoms. Thus, when monitoring the outcome of treatment it is important to assess improvement of symptoms as well as objective evidence of eradication.     

Role of Helicobacter pylori in gastrointestinal disease: implications for primary care of a revolution in management of dyspepsia.

The majority of patients with dyspepsia are managed in general practice. However, most of the literature on Helicobacter pylori and its association with gastrointestinal disease has originated from secondary care. This review summarizes the role of H pylori in dyspepsia from the perspective of primary care and suggests a new strategy for the management of dyspeptic patients in this setting. Recent meta-analyses and consensus statements have supported the use of eradication therapy as first-line treatment of peptic ulceration. Studies from primary care have supported the use of eradication therapy in patients who have H pylori related peptic ulcer disease and require long-term H2-antagonist medication, on both clinical benefit and cost-effectiveness grounds. Of the many regimens proposed for the eradication of H pylori, the best evidence supports a triple combination of bismuth, metronidazole and tetracycline. Regimens using proton pump inhibitors may be more acceptable to patients but lack good evidence from trials. Use of a positive serum enzyme-linked immunoabsorbent assay for H pylori antibodies as a criterion for endoscopic investigation has been shown to result in a 23% reduction in endoscopic workload. Further research should answer questions of importance to general practitioners, such as the role of eradication therapy in patients with nonulcer dyspepsia and the effectiveness of eradication of H pylori in the prevention of gastric cancer.