Treatment of Helicobacter pylori infection: The past and the future

Abstract

0953-6205/$ – see front matter © 2010 Euro doi:10.1016/j.ejim.2010.07.009 Helicobacter pylori (H. pylori) is a worldwide infection that affects millions of people. This infection is the main cause of gastritis, gastroduodenal ulcer disease, and gastric cancer. After more than 20 years of experience inH. pylori treatment, however, the ideal regimen to treat this infection has still to be found [1,2]. Themost recommended treatment for the eradication of H. pylori, in all international guidelines, is the so called standard or proton pump inhibitor (PPI) triple therapy, which includes the combination of two antibiotics (clarithromycin plus amoxicillin or metronidazole) with a PPI for at least 7 days [3,4]. However, H. pylori eradication rates with standard triple therapy have fallen from initial heights of N90% to 75–80% in some areas [5–9]. As an example, two recent double-blind, U.S. multicenter studies both found disappointingly low eradication rates with standard therapy: 77% [10,11]. Furthermore, two meta-analyses including more than 53,000 patients showed that the cure rate is, at present, below 80% [12,13]. In summary, eradication rates in most western countries have declined to unacceptable levels [2,14], probably due to increased resistance to antibiotics. In particular, antibiotic resistance to clarithromycin has been identified as one of themajor factors affecting our ability to cureH. pylori infection, and the rate of resistance to this antibiotic seems to be increasing in many geographical areas [15]. The ethics of continued use of standard triple therapy has recently been questioned and the use of alternative therapy has been recommended in its place [16]. Therefore, new strategies in order to improve first-line treatment are still urgently needed. Attempts to increase the duration of triple therapy and therefore prolong exposure to antibiotics have achieved controversial results, but, in general, have