Hello. I am Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.
Helicobacter pylori treatment has changed the natural history of peptic disease in this country and around the world. In addition, such treatment has affected other consequences of H pylori, in particular some of the mucosa-associated lymphoid tissue (or MALT) lymphomas and other specific disease categories that benefit from its eradication. But the treatment has changed.
Years ago, when H pylori was discovered, standard treatment involved a 7-day regimen of a proton pump inhibitor (PPI) plus amoxicillin and clarithromycin for patients who could tolerate it. Metronidazole was a substitute for amoxicillin in patients who were penicillin allergic. There has been a component alternative with bismuth-based therapies for patients who have amoxicillin allergy or clarithromycin resistance: a tetracycline/metronidazole/bismuth combination plus a PPI. This is a 10-day regimen.
We have seen, however, that the efficacy of these regimens has declined. This prompted a group of primarily Canadian experts on H pylori and evidence-based medicine to convene a 2-year analysis that culminated in a final evaluation in Toronto, Canada—hence, the Toronto Consensus Conference on Helicobacter pylori Infection in Adults.[1,2] This consensus conference resulted in several important take-home messages that should change the way we practice and treat H pylori.
High Rates of Drug Resistance
First, recognize that drug-resistance patterns have changed during the past decade and a half.[1] Clarithromycin resistance, which was initially quite low, at 1%-8%, has risen to 16%-24%. Metronidazole resistance was relatively high to begin with and has remained relatively stable at 20%-40%. Tetracycline resistance and amoxicillin resistance are virtually unheard of at less than 1% for tetracycline and 1%-3% for amoxicillin, and thus they remain incredibly good drugs.
As we try to proactively restrict antibiotics when we do not need to use them, we need to keep in context our efforts at limiting antibiotic exposure. As we have seen these drugs used repeatedly for a variety of diseases and treatments—urinary tract infections, bronchitis, and so on—the prevalence of secondary resistance for clarithromycin and metronidazole has gone up dramatically. Resistance is up to 67%-82% for clarithromycin and 52%-77% for metronidazole.[1] Thus, the effectiveness of these drugs has been drastically reduced. Once you have used them, you have pretty much used the last bow in the quiver and you cannot use these drugs again.
Consensus Recommendations
The Toronto Consensus Conference looked at evidence from 2008 forward; they avoided the earlier reports because of eradication, resistance patterns, and so on. They concluded that extending the treatment from 7 or 10 days to 14 days is and should be the new standard. The eradication rates for the 7- to 10-day regimens have fallen to approximately 50%, whereas with a 14-day regimen by either intention-to-treat or per protocol, the eradication rates were in excess of 95%. Therefore, a regimen lasting 14 days is the new rule across all treatment regimens for H pylori, regardless of which line of therapy is used.[1]
Specifically, in areas where resistance patterns are known, therapy should be based on the resistance pattern. Now, in clinical practice we do not generally look at resistance patterns and we do not culture our H pylori. In fact, I cannot think of a single time that I have cultured for resistance patterns in 36 years of practice. Nonetheless, we certainly respect the results reported in scientific journals even though scientific journals do not always reflect our clinical practice. Clinical practice would say that we know the patients have H pylori and we treat that. So what do we do? Continue Reading
Hello. I am Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.
Helicobacter pylori treatment has changed the natural history of peptic disease in this country and around the world. In addition, such treatment has affected other consequences of H pylori, in particular some of the mucosa-associated lymphoid tissue (or MALT) lymphomas and other specific disease categories that benefit from its eradication. But the treatment has changed.
Years ago, when H pylori was discovered, standard treatment involved a 7-day regimen of a proton pump inhibitor (PPI) plus amoxicillin and clarithromycin for patients who could tolerate it. Metronidazole was a substitute for amoxicillin in patients who were penicillin allergic. There has been a component alternative with bismuth-based therapies for patients who have amoxicillin allergy or clarithromycin resistance: a tetracycline/metronidazole/bismuth combination plus a PPI. This is a 10-day regimen.
We have seen, however, that the efficacy of these regimens has declined. This prompted a group of primarily Canadian experts on H pylori and evidence-based medicine to convene a 2-year analysis that culminated in a final evaluation in Toronto, Canada—hence, the Toronto Consensus Conference on Helicobacter pylori Infection in Adults.[1,2] This consensus conference resulted in several important take-home messages that should change the way we practice and treat H pylori.
High Rates of Drug Resistance
First, recognize that drug-resistance patterns have changed during the past decade and a half.[1] Clarithromycin resistance, which was initially quite low, at 1%-8%, has risen to 16%-24%. Metronidazole resistance was relatively high to begin with and has remained relatively stable at 20%-40%. Tetracycline resistance and amoxicillin resistance are virtually unheard of at less than 1% for tetracycline and 1%-3% for amoxicillin, and thus they remain incredibly good drugs.
As we try to proactively restrict antibiotics when we do not need to use them, we need to keep in context our efforts at limiting antibiotic exposure. As we have seen these drugs used repeatedly for a variety of diseases and treatments—urinary tract infections, bronchitis, and so on—the prevalence of secondary resistance for clarithromycin and metronidazole has gone up dramatically. Resistance is up to 67%-82% for clarithromycin and 52%-77% for metronidazole.[1] Thus, the effectiveness of these drugs has been drastically reduced. Once you have used them, you have pretty much used the last bow in the quiver and you cannot use these drugs again.
Consensus Recommendations
The Toronto Consensus Conference looked at evidence from 2008 forward; they avoided the earlier reports because of eradication, resistance patterns, and so on. They concluded that extending the treatment from 7 or 10 days to 14 days is and should be the new standard. The eradication rates for the 7- to 10-day regimens have fallen to approximately 50%, whereas with a 14-day regimen by either intention-to-treat or per protocol, the eradication rates were in excess of 95%. Therefore, a regimen lasting 14 days is the new rule across all treatment regimens for H pylori, regardless of which line of therapy is used.[1]
Specifically, in areas where resistance patterns are known, therapy should be based on the resistance pattern. Now, in clinical practice we do not generally look at resistance patterns and we do not culture our H pylori. In fact, I cannot think of a single time that I have cultured for resistance patterns in 36 years of practice. Nonetheless, we certainly respect the results reported in scientific journals even though scientific journals do not always reflect our clinical practice. Clinical practice would say that we know the patients have H pylori and we treat that. So what do we do? Continue Reading