Eradication of Helicobacter pylori: A Clinical Update

Marco Romano, MD; Antonio Cuomo, MD

In This Article

Future Directions

Therapeutic regimens directed against H pylori infection will continue to evolve. What is required is a well-tolerated monotherapy specific for H pylori, which therefore does not induce resistance in other organisms. This possibility may be realized now that the H pylori genome has been sequenced. However, with no new development of anti-H pylori antimicrobial agents expected anytime soon, research efforts will continue to focus on improved eradication rates through adjustments in dosing and combinations of available medications. In this regard, Zullo and colleagues[42] have recently reported that 5-day treatment with rabeprazole 20 mg twice daily plus amoxicillin 1 g twice daily followed by 5-day triple-drug treatment with rabeprazole 20 mg twice daily plus tinidazole 500 mg twice daily plus clarithromycin 500 mg twice daily was significantly more effective than the standard 7-day regimen in a randomized, controlled study involving approximately 1000 H pylori-infected patients. The eradication rate associated with this sequential regimen was 92% compared with 77% obtained with standard triple therapy.

It has also been reported that probiotics may exert a favorable effect on H pylori gastritis and significantly reduce the incidence of side effects related to antimicrobial therapy.[43] Moreover, the efficacy of a standard PPI-based triple-therapy regimen was significantly increased by adding bovine lactoferrin in an open, randomized, single-center study,[44] whereas human recombinant lactoferrin was ineffective in the treatment of human H pylori infection.[45]

In our opinion, given the limited number of effective drugs available, clinicians should try to optimize the use of these drugs by treating H pylori infection as they would any infection, thus establishing the in vitro sensitivity of the clinical isolates to antimicrobials before initiating treatment. The major obstacle to this approach is the invasive nature of the endoscopy exam used to obtain gastric mucosal samples for culture and testing and, therefore, efforts should be made to obtain samples of gastric mucosa in a less invasive manner. Development of H pylori strains with no infectivity may become a reality, and further knowledge of genomics may help in identifying the virulent strains. Targeting these virulent strains and developing aggressive eradication strategies aimed specifically at population subgroups may represent the path forward.