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Indication for H. pylori Eradication
Treatment for H. pylori in asymptomatic carrier, in order to decrease reservoir of infection in community and to prevent the development of various conditions caused by H. pylori, is controversial and supported by only a few studies. It is advised that it should be treated only if chronic carrier status is proved to initiate the disease process.
 
 
Non-ulcer Dyspepsia
Treatment for H. pylori associated with symptoms of non-ulcer dyspepsia is also controversial and at present there is no convincing evidence that H. pylori is responsible for theses symptoms. Moreover, prevalence of H. pylori in this group of patients is not higher than the general population without symptoms. Although a subset of patients may have their symptoms due to presence of H. pylori, there is no clear to presence of H. pylori, there is no clear to evidence that they benefit after H. pylori eradication. At present there is no indication that patients with non-ulcer or functional dyspepsia should be treated for H. pylori, till the results from large trials are available.
 
 
Duodenal and Gastric Ulcer
It has now been well established that H. pylori is the main cause of most of the duodenal ulcers the main cause of most of the duodenal ulcers and chronic benign gastric ulcers that are not associated with NSAIDs. More than 95% of Patients with duodenal ulcer are positive for H.pylori and eradication of infection results in rapid healing and a dramatic decrease in relapse rate to less than 5 percent each year. Duodenal ulcer heals completely after the eradication therapy and a course of antisecretory drugs after healing is not required, unless it is associated with complications like recent hemorrhage, perforation, etc. There is some data suggesting prevention of recurrence of bleeding from ulcer after eradication of H. pylori. Those who have recurrence of symptoms after successful eradication without recurrence of duodenal ulcer other causes for such symptoms like gastroesophageal reflux disease, gallstones should be investigated. The clinical benefit of H. pylori eradication in NSAIDs induced duodenal or gastric ulcer is not well established. However, there is some evidence that NSAIDs induced mucosal damage may be less in the absence of H. pylori and thus there is some justification to eradicate H. pylori in NSAIDs induced gastric or duodenal ulcer.

Though there is a strong circumstantial evidence to link the H. pylori infection with the development of gastric adenocarcinoma and WHO has classified H. pylori as group I definite carcinogen, less than 1 percent of H. pylori infected individuals will ever develop gastric cancer and so far there is no evidence that, eradication of H. pylori will decrease the risk of gastric cancer. It is also not known where exactly the point of no return is in the gastritis-atrophy-metaplasia-dysplasia-cancer sequence of events. With a family history of gastric cancer, if an individual has an evidence of atrophy, metaplasia or dysplasia in early life, he may be offered H. pylori eradication treatment. H. pylori infection has been associated with MALT lymphoma, which subsequently develops into malignant lymphoma. It has been found that H. pylori specific T-lymphocytes act as a growth stimulant for MALT, which suggests that early tumour may respond if this stimulus is withdrawn. H. pylori eradication therapy results in regression of low-grade B-cell gastric lymphoma of MALT type.

Epidemiological evidence has suggested that H. pylori infection is also associated with non-Hodgkin's lymphoma but there is no data on effect of H. pylori eradication in this condition.

H. pylori infection has been found in more than 90 percent patients with hypertrophic gastropathy (Menetrier's disease). Eradication of H. pylori has been reported to return the stomach and protein concentration to normal in this condition.
 
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Eradication Regimens24-34
H. pylori infection can be cured with antibacterial therapy and with presently available combination more than 90 percent eradication can be achieved. The present therapeutic standards are clear, eradication in atleast 90 percent after one week of treatment and less than 5 percent of the patients dropout from the treatment because of side effects. It should be remembered that all currently available treatment are associated with side effects. Various therapeutic regimens that have been tried are as follows:

Monotherapy: Single drug therapy is not effective in eradication of H. pylori. With a single antibiotic, eradication rate has been reported from 0-54 percent. Clarithromycin has been found as the most effective single drug. However a single antibiotic should not be prescribed as it is not only ineffective but also it may produce a resistant strain. H2 -receptor antagonists have no effect on H. pylori and despite in vitro effect of PPI on H. pylori, they are not effective in eradicating the bacteria. Bismuth compounds suppress the H. pylori, but as monotherapy, bismuth does not eradicate this bacteria. Due to the ineffectiveness and possibility of development of resistant strain, monotherapy is not recommended.

Dual therapy: Combinations that have been tried for eradication of H. pylori include two antibiotics; H2 receptor antagonists with antibiotics; bismuth with antibiotics; omeprazole (PPI) with clarithromycin. Combination of any two antibiotics is not effective in H. pylori eradication. High dose H2RAs given along with antibiotic (amoxicillin or clarithromycin) for two weeks may eradicate H. pylori in upto 60 percent of patients. Colloidal bismuth subcitrate (CBS) with metronidazole have been found effective in almost 85 percent in small studies. Ranitidine bismuth citrate (RBC) in combination with either amoxicillin or clarithromycin given for two weeks has shown eradication rate from 65 percent to 80 percent depending upon the dosage.

Triple Therapy: Various combinations of three drugs have been tried. Drugs that have been used in triple therapy are CBS, RBC, H2RA, PPI, amoxicillin, tetracycline, clarithromycin, metronidazole and tinidazole. There are wide dosage variations and different treatment schedules with eradication rate varying from 35 to 95 percent have been reported in the literature. Such different findings are because of dissimilarities in patient populations, resistance to metronidazole and other antibiotics and variation in compliance by the patients. Classical triple therapy given for seven days has not been always successful. On the contrary, there is not further benefit if the treatment is given for 14 days or more. Tetracycline or amoxicillin based therapy has no significant difference in eradication. The combinations used for triple therapy are; bismuth + antibiotics + PPI, H2RA + metronidazole + amoxicillin, PPI + Metronidazole/tinidazole + amoxicillin/clarithromycin. Newer PPIs like lansoprazole and pantoprazole also have been used in these combinations. Various combinations with their efficacies are shown in Tables II-IV.

Quadruple Therapy: Combination of four drugs also has been tried, though these have more side effects and compliance problems. Drugs that have been given for one week in this combination were omeprazole (20mg bid), CBS (120mg bid), tetracycline (550mg bid) and metronidazole (500 mg bid). The eradication rate was 96 percent.
Table 2 : Dual Therapy With Amoxycillin35
  Omeprazole Amoxycillin Ranitidine Bismuth Citrate, Amoxicillin
Dosing 20-40 mg bid. 500mg qid or 1g bid 400-800 mg bid. 500 mg qid
Duration 2 weeks 2 weeks
Hp Eradication 50-85% 65%
Side Effects common: diarrhoea common: diarrhoea
 
Table 3: Dual Therapy With Clarithomycin35
  Omeprazole Clarithromycin Ranitidine Bismuth Citrate,
Clarithromycin
Dosing 40 mg bid. 500mg tid 400 mg bid. 500 mg bid
Duration 2 weeks 2 weeks
Hp Eradication 60-80% 80%
Side Effects Common: taste disturbances, diarrhoea Common: taste disturbances,
diarrhoea
 
Table 4 : Low-Dose,1 Week Triple Therapies35
  PPI
Clarithromycin
Metronidazole		 PPI
Amoxicillin
Clarithromycin		 PPI
Amoxicillin
Metronidazole
Dosing od or bid. 250mg bid
400 mg bid		 bid. 1g bid.
250-500mg bid		 a.d. 500mg tid. 400 mg tid
Duration 7 days 7 days 7 days
Hp Eradication 85-95% 85-95% 75-90%
Side Effects Minimal: nausea common: diarrhoea,
nausea		 common: diarrhoea,
nausea
 
Table 5 : Triple Therapy Combinations With Amoxycillin And Metronidazole35
  CBS
Amoxicillin
Metronidazole		 PPI
Amoxicillin Clarithromycin
Metronidazole		 PPI
Amoxicillin
Metronidazole
Dosing 120mg q.i.d
500 mg qid
200-400 mg qid		 od. 500mg tid. 400mg tid a.d. 750mg tid. 500 mg tid
Duration 2 weeks 1 week 12 days
Hp Eradication 60-90% 75-90% 68-90%
Side Effects common: diarrhoea ,nausea common: diarrhoea,
nausea		 common: diarrhoea,
nausea
 
It is very difficult to eradicate metronidazole resistant H. pylori. Combination therapy consisting metronidazole may be very effective against metronidazole resistant strains (eradication rate may be less than 50%). Primary or acquired metronidazole resistance of H. pylori is 20-30 percent in western countries and as high as 66 percent in India. Metronidazole or tinidazole resistance may be reduced by combining with bismuth or by giving quadruple therapy for 10 days.

In spite of large available data, it is yet not possible to give final recommendation as to the best regimen to eradicate H. pylori as there are very few large trials. It is quite likely that there is no significant difference between triple and quadruple regimens. The effective eradication also depends upon other factors like compliance, metronidazole resistant status and side effects of the drugs. Cost is also an important consideration and also the relapse rate. However, for all practical purposes the triple drug regimen in a suitable combination is preferable for the treatment of H. pylori infection. In high metronidazole resistant areas preference should be given to a combination without metronidazole.

Acknowledgement: Journal Of Indian Academy Of Clinical Medicine ; 2000 April-June,Vol 5(2); 148-155
 
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References

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