Efficacy of a multistep strategy for Helicobacter pylori eradication

Background: Helicobacter pylori eradication therapies do not achieve 100% s uccess rates. Antibiotic resistant strains are among the major causes of fa ilure. Current recommendations concerning the management of treatment failu res are not fully clear. Aim: To evaluate the efficacy of a multi-step therapeutic strategy in a lar ge group of infected patients. Methods: A total of 2606 H. pylori-positive patients were administered tini dazole, clarithromycin and a proton pump inhibitor for 1 week. Patients wit h continuing infection were then given a second 1-week course of amoxycilli n, clarithromycin and ranitidine bismuth citrate. Patients still infected a fter the second course underwent upper gastrointestinal endoscopy with H. p ylori culture, and then received a 1-week quadruple proton pump inhibitor-b ismuth based scheme established on H. pylori antibiotic sensitivity. Results: After the first step, eradication was achieved in 2063 out of 2413 patients [86% per protocol analysis (PP); 79% intention-to-treat analysis (ITT)]. First-step failures (350 out of 2413; 14.5% PP) showed second-step eradication rates of 82% (271 out of 329 patients, PP; 77% ITT). The specif ic quadruple therapy for second-step failures (58 out of 329, 18% PP) achie ved 77% (30 out of 39 patients, PP) or 52% (ITT) success. This algorithm le d to overall eradication rates of 99% (PP) or 91% (ITT). Conclusions: This multi-step strategy succeeded in a high percentage of H. pylori infected patients. Given the lack of precise guidelines on treatment failures, assessing H. pylori sensitivity to antibiotics only after failur e of the second treatment could be suggested in clinical practice.