Eradication of Helicobacter pylori: A Clinical Update

Marco Romano, MD; Antonio Cuomo, MD

In This Article

Therapy of H pylori Infection

The management of H pylori gastritis involves a 3-step approach: diagnose, treat, and confirm cure. The availability of accurate and noninvasive tests, such as the urea breath test or stool antigen test, has rendered confirmation of cure practical. The location of H pylori within the stomach (eg, the mucus lining the surface epithelium or the surface of mucous cells) provides a challenge for antimicrobial therapy. In addition, the gastric lumen is a hostile environment for antimicrobial therapy because the drugs must penetrate thick mucus and may need to be active at pH values below neutral. Successful therapy requires a combination of drugs that prevent the emergence of resistance and reach the bacteria within its various niches. Therapy must ensure that a small population of bacteria does not remain viable. Eradication is defined as the presence of negative tests for H pylori 4 weeks or longer after the end of antimicrobial therapy. Clearance or suppression of H pylori may occur during therapy, and failure to detect H pylori on tests done within 4 weeks of the end of therapy may give false-negative results. The latter is because clearance or suppression is swiftly followed by recurrence of the original infection.

Treatment regimens for H pylori infection have been evolving since the early 1990s, when monotherapy was first recommended. Antimicrobial therapy for this infection is a complex issue, and the results from new combination treatments are often unpredictable. Errors that should be avoided include quick adoption of regimens tested only in small populations and substitution of 1 well-studied, effective medication for another in the same class. Also, it is important to validate the success rate of a treatment regimen in each country, and perhaps even in the specific region of each country, where its use is intended.