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| Treatment |
H. pylori eradication therapy is a matter
of continuing debate. The number and type of combinations are
innumerable. The data accumulated in this area is a matter of
much confusion for a practitioner faced with such a common problem.
The first rule is not to use a single agent for treatment. All
single agents have given eradication rates below 50% and are
not acceptable in clinical management. The second rule is to
use a strong acid suppressant drug along with antibiotic combination.
Hypochlorhydria during antibiotic therapy enhances H. pylori
eradication rates. Of great importance is the data that strong
acid suppressant therapy, particularly with proton pump inhibitors
(PPIs), overcomes resistance to metronidazole and possibly other
antibiotics. Thirdly, antibiotic sensitivity pattern of H. pylori
in the geographical region of practice needs to be kept in mind.87-98
Over the years, the two combinations, which have shown consistently
high eradication rates are shown. Most European studies use
one-week triple therapy while North American studies use two
-week therapy for high eradication rates. A recently introduced
combination popularly named the RBC-based triple therapy combines
ranitidine and bismuth and two antibiotics, namely, clarithromycin
and amoxicillin. This combination has given consistently high
eradication rate comparable to standard triple therapy (Table
2). Antibiotic resistance to H. pylori is a problem, which shall
become of great significance in future. To date, metronidazole
resistance is seen in a high percentage of patients particularly
in developing countries. |
Clarithromycin resistance occurs from 1%-12% of patients and
amoxicillin resistance is rare. Is antibiotic resistance of
clinical importance as of today? Data show that when there is
no resistance, eradication rates approach 100%. When there is
resistance to one antibiotic, the risk of treatment failure
increases, but eradication rates remain high and clinically
acceptable. Resistance to two agents drops the eradication rate
to less than 50%. Of significance is the data that PPI therapy
does overcome a high degree resistance to metronidazole and
clarithromycin. Metronidazole resistance is defined as minimal
inhibitory concentration (MIC) of 8 ug/mL or more. However,
there is no clear association between resistance and treatment
failures until MIC is above 32 ug/mL. Clarithromycin resistance
is defined as MIC of 1 ug/mL or more. Treatment failures occur
only when clarithromycin resistance reaches a high grade with
MIC of 128 ug/mL.87
The high prevalence of H. pylori infection in the world, its
implications in the appearance of gastric malignancies and the
emergence of antibiotic resistance demand that prophylactic
and new measures are developed against this infection. Two types
of oral vaccines are being intensely studied. Candidate preventive
vaccines include crude sonicates of Helicobacter felis and recombinant
subunits of enzyme urease and catalase. A human vaccine using
urease and heat labile enterotoxin of E. coli is already under
field trial. Candidate treatment vaccine has had success in
infected mice and clears the infection by hosting an immune
response. The oral antigens used in these two types of vaccines
have been shown to result in T-helper cell-2 driven immune response,
which in turn stimulates Blymphocytes. Natural immunity to H.
pylori in contrast is a T-helper-1 driven response, which has
no value in clearing or preventing the infection.99-100
H pylori status in the Middle East
The prevalence of H. pylori in the Middle Eastern population
is around 60%. The epidemiology of the infection in this region
resembles those of many other developing countries.101 It is
significant that standard PPIbased triple therapy for one or
two weeks gives H. pylori eradication rate of 65% at best. This
low eradication rate was exclusively related to high percentage
and high-grade resistance to first-line antibiotics used in
the therapy (Figure 5). In view of the above, newer drug combinations
need to be explored for H. pylori eradication therapy in this
region.102 |
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