774 Perceptions of Training Among Program Directors and Trainees in Complex Endosopic Procedures (CEPs): A Nationwide Survey of US ACGME Accredited Gastroenterology Training Programs

Abstract

Background: Insufficient inhibition of gastric acid during Helicobacter pylori treatment and bacterial resistance to antibiotics frequently results in failure to eradicate infection. Twicedaily dosing (b.i.d.) of a proton pump inhibitor (PPI) using standard eradication therapy has shown difficulty in maintaining high gastric pH values for 24 h in patients. However, four-times-daily dosing (q.i.d.) achieves these goals, irrespective of CYP2C19 genotype status, and might therefore be an optimal regimen for use in eradicating H. pylori infection. The fluoroquinolone sitafloxacin (STFX) was recently reported to have a lower minimum inhibitory concentration for H. pylori compared with levofloxacin and has become clinically available as a third-line treatment and for patients with penicillin allergy. An STFX-based eradication regimen with maintenance of acid inhibition might therefore have a high success rate. We investigated the efficacy of this treatment and maintenance of acid inhibition by PPI q.i.d. treatment. Methods: In 136 H. pylori-positive Japanese patients (for first-line treatment: n=40, second-line: n=30, third-line: n=66), the efficacy of the following treatment regimen was investigated: a PPI (rabeprazole 10 mg, q.i.d.), metronidazole (250 mg, b.i.d.), and STFX (100 mg, b.i.d.) for 1 week, irrespective of CYP2C19 genotype status and numbers of previous eradication therapy. At four to eight weeks after treatment, patients underwent the [13C]-urea breath test to assess successful eradication. Results: First-resistance to antimicrobial agents was 51.4% for clarithromycin, 56.7% for metronidazole and 30.0% for levofloxacin. The intention-to-treat eradication rate in the tailored group was 93.4% (95%CI: 87.8%-96.9%, 127/136). Although the eradication rate in patients treated as first-line therapy (100%, 95%CI: 92.8%-100%, 40/40) was higher than that in those treated as second-line (93.3%, 95%CI: 77.9%-99.2%, 28/30) and third-line therapy (89.4%, 95%CI: 87.8%-96.9%, 59/66), no significant differences were shown among numbers of previous eradication therapy (p = 0.08). The eradication rates were similar among all three CYP2C19 genotype groups (extensive metabolizer, 91.7% [66/73]; intermediate metabolizer, 96.1% [49/51]; poor metabolizer, 91.7% [11/12]), exceeding 90% for all genotypes. Conclusions: A sitafloxacinbased H. pylori eradication regimen based on maintaining acid secretion (rabeprazole 10 mg, q.i.d.) achieved an eradication rate of more than 90%, irrespective of eradication history and CYP2C19 genotype. In addition, as this regimen reduces the cost of CYP2C19 genotyping and culture tests, it might be more cost-effective than CYP2C19 genotype-based treatments.