Bismuth Triple Therapy Research Articles

An Update on Eradication of Helicobacter Pylori in Iran: A Review.

Helicobacter pylori, the most prevalent infection in the world, has great importance due to being related to peptic ulcer disease, gastric metaplasia, dysplasia, and even gastric adenocarcinoma or mucosa-associated lymphoid tissue (MALT) lymphoma. The standard H. pylori eradication regimen is based on antibiotic susceptibility testing. If susceptibility testing is not available, a standard treatment regimen will be recommended based on records of H. pylori resistance rates to antibiotics in a region or locally proven highly effective regimens (equal to or higher than 90% eradication rate). The aim of this review was to define suitable recommendations for local treatment in different cities of Iran. This review article consists of randomized controlled trials related to H. pylori eradication in Iran. Data including the kind of therapy, number of patients and per-protocol H. pylori eradication rates were recorded in data gathering forms. Data search was conducted in PubMed and Google Scholar databases from 2018 to December 2023. According to our review of Iranian articles regarding first-line H. pylori eradication regimens, these treatment protocols could be recommended: Bismuth-clarithromycin quadruple therapy in Ardabil, bismuth-clarithromycin quadruple therapy with probiotics in Birjand, standard triple therapy in Ilam, bismuth quadruple therapy or bismuth triple therapy or concomitant regimen in Sari, sequential therapy in Tehran and bismuth quadruple therapy in Yazd. These regimes can be extended to other regions that have a similar situation. According to the reports of Iranian researchers, a quinolone-containing regimen (levofloxacin preferred) is recommended for second-line eradication therapy. Various H. pylori eradication regimens can be used as first-line therapy; however, choices for second-line therapy are limited. We recommend the quinolone-containing regimens as the preferred second-line therapy.

Correlation between distribution of Helicobacter Pylori in oral cavity and chronic stomach conditions

In this study, the colonization and distribution of Helicobacter pylori (Hp) in patients with chronic gastric diseases were investigated and the relationship between the periodontal initial treatment and presence of Hp in oral cavity was examined to better understand the connection between Hp infection and chronic diseases. Primers for PCR amplification were designed according to ureC gene and cagA genes of Hp. Specimens were harvested from different sites of 96 patients with chronic gastric diseases and the specimens of dental plaques, gargles and dorsal mucosa were tested for Hp. The 96 patients were treated by bismuth triple therapy and among them, 52 subjects were additionally given periodontal initial therapy. The eradication rate of gastric Hp and oral Hp detection rate were determined 4 weeks and 1 year after the treatment. The results showed that the detection rates of oral specimens were in the order of dental plaques (82.3%), gargles (51.1%) and scrapings of dorsal mucosa of tongue (37.5%). One year after bismuth triple therapy or the triple therapy in combination with periodontal initial treatment, the eradication rate of gastric Hp was significantly higher in the combination treatment group than in group treated by the triple therapy alone (62.8% vs. 32.4%, P<0. 05). Moreover, the Hp detection rate was significantly lower in the combination group than in the group treated only with the triple therapy. We are led to conclude that Hp is present at various parts of oral cavity, oral Hp might be an important source of gastric Hp and the triple therapy plus periodontal initial treatment can enhance the long-term eradication rate of gastric Hp in patient with both chronic gastric diseases and chronic periodontitis.

Nifuratel-Containing Initial Anti-Helicobacter pyloriTriple Therapy in Children

Proton pump inhibitor-containing triple therapy with amoxicillin and metronidazole is recommended as initial treatment of Helicobacter pylori in childhood. However, eradication rate with this "classic" regimen is relatively low in Russia. To evaluate empiric nifuratel, amoxicillin, and bismuth triple therapy for H. pylori gastritis in childhood. Pediatric outpatients with H. pylori-associated chronic gastritis who underwent endoscopy for dyspeptic symptoms received the combination of bismuth subcitrate (8 mg/kg/day, q.d.s.), nifuratel (30 mg/kg/day, q.d.s.), and amoxicillin (50 mg/kg/day, q.d.s.) for 10 days. H. pylori status was determined before and after the treatment (in 4-6 weeks) by modified Giemsa staining. Seventy-three children (48 boys, 25 girls, age range 9-14) were entered. H. pylori was eradicated in 63 patients (86%; 95% confidence interval: 76.6-93.2; intention-to-treat and per protocol). There were no serious adverse reactions and were no withdrawals due to any side-effects. All of side-effects were self-limiting (dark stools, urine discoloration, blackening of the tongue, and others). The combination of nifuratel, bismuth subcitrate, and amoxicillin was an effective and tolerable regimen for H. pylori eradication.

2-Weeks ȁrescueȁ therapy after H. Pylori eradication failure: sequential bismuth-triple therapy versus quadruple therapy

2-Weeks ȁrescueȁ therapy after H. Pylori eradication failure: sequential bismuth-triple therapy versus quadruple therapy

A randomized comparison of quadruple and triple therapies for Helicobacter pylori eradication: The QUADRATE study

Background & Aims: Direct comparisons of bismuth and proton pump inhibitor (PPI)-based triple and quadruple therapies for Helicobacter pylori eradication are lacking. To address this, a randomized study was conducted. Methods: Infected dyspeptic patients received pantoprazole 40 mg, amoxicillin 1000 mg, and clarithromycin 500 mg, all twice daily, for 7 days (PAC7); or pantoprazole 40 mg twice daily, bismuth subcitrate 108 mg, and tetracycline 500 mg, both 4 times daily, and metronidazole 200 mg 3 times daily and 400 mg at night for 7 days (PBTM7); bismuth subcitrate 108 mg and tetracycline 500 mg, both 4 times daily, and metronidazole 200 mg 3 times daily and 400 mg at night for 14 days (BTM14). Outcome was assessed with 13C-urea breath test. Results: Eradication rates (intention to treat [n = 405]/per protocol [n = 320]) were similar for PAC7 (78%/82%) and PBTM7 (82%/88%); the latter significantly superior to BTM14 (69%/74%; P < 0.01). Pretreatment metronidazole resistance (MR) was 53% and clarithromycin resistance was 8%. Eradication rates for primary metronidazole sensitive/resistant isolates were 74%/87% with PAC7 and 80%/81% for PBTM7, compared with 76%/55% (P < 0.02) for BTM14. Noncompliance was greater with BTM14 (15%; P < 0.001) than PAC7 (3%) or PBTM7 (6%). Moderate-severe adverse events were more common with BTM14 (45%; P < 0.001), than PAC7 (23%) or PBTM7 (25%) with more discontinuations (9%, 2%, 3%, respectively). Conclusions: One-week PPI triple therapy is well tolerated and effective. The addition of PPI to bismuth triple therapy allows reduction of treatment duration with improved efficacy and tolerability, despite a high rate of MR. Quadruple therapy appears to overcome pretreatment MR in most cases. Two-week bismuth triple therapy is significantly inferior to quadruple therapy and less well tolerated than both 1-week therapies.GASTROENTEROLOGY 2002;123:1763-1769

Effect of eradicating Helicobacter pylori on the development and reversion of atrophic gastritis in an animal study

OBJECTIVE: To investigate the effect of eradicating Helicobacter pylori on the development and reversion of atrophic gastritis in an animal study. METHODS: One hundred and ten grade II C57BL/6 female mice were randomly divided into experimental (60 mice) and control (50 mice) groups. The mice in the experimental group were infected with the SS1 H. pylori strain, then randomly subdivided into group A and group B (30 mice in each group). Group A and group B received a dose of standard bismuth triple therapy 6 and 12 months after infection, respectively. Ten mice in each group were killed before the therapy, then at 3 and 6 months after completion of the therapy (a total of 30 mice). The histopathological features of the glandular stomach were graded using a method analogous to the Sydney system and kinetic changes in the mucosal epithelial cells of the glandular stomach were examined using anti‐BrdU immunohistochemical staining and flow cytometry. RESULTS: All mice that received eradication therapy tested negative for Helicobacter pylori. Significant improvement in chronic active gastritis was observed after the eradication of H. pylori in both groups A and B. Atrophic changes were not seen at any time interval in group A, whereas in group B, atrophic changes were seen 12 months after H. pylori infection and no significant changes in the degree of atrophy were observed 3 and 6 months after the eradication of H. pylori. The cell kinetic indices (S‐phase cell percentage, proliferation index and labeling index) in the experimental group before the eradication of H. pylori were significantly higher than those in the control group at any time (P &lt; 0.01), and significantly decreased 3 months after the eradication of H. pylori compared with those before therapy (P &lt; 0.01). The cell kinetic indices showed no significant difference 6 months after the eradication of H. pylori compared with those in the control group at the same time intervals (P &gt; 0.05). CONCLUSIONS: The present study suggests that the eradication of H. pylori can reduce gastric mucosal inflammation and change the epithelial cell kinetics of the stomach. It was found that early treatment can prevent the formation of mucosal atrophy. When atrophy has established, eradication of H. pylori can no longer reverse the change but may prevent its progress.

Ulcers and gastritis.

Once again this year, developments in the field of ulcers and gastritis have been entirely dominated by findings relating to Helicobacter pylori. However, interest in H. pylori can be expected to decline, since the prevalence of the infection is rapidly decreasing in the developing world - to the point that many gastroduodenal ulcers are now unrelated to H. pylori A further reason for declining interest is disappointment regarding the role of H. pylori in dyspepsia. The expected reduction in the endoscopic workload produced by screening for H. pylori or cagA positivity has so far not occurred. The exact role of the damage caused by nonsteroidal anti-inflammatory drugs in H. pylori-infected stomachs remains controversial. Equally controversial is the magnitude of the increased reflux symptomatology and reflux disease observed after H. pylori infection has been cured in patients with ulcer disease. Eradication therapy is largely dominated by proton-pump inhibitor triple therapies, although the efficacy of these is declining. Bismuth triple therapy and quadruple therapy continue to be valid alternatives.

A single drug for Helicobacter pylori infection: first results with a new bismuth triple monocapsule

OBJECTIVE: In this pilot study we investigated the efficacy and tolerability of a new monocapsule that contains a bismuth compound, tetracycline, and metronidazole. If proven to be effective, this monotherapy would turn the well-accepted multidrug regimen of standard bismuth-based triple therapy into an easy and more patient-friendly regimen. It can be used in patients allergic to penicillin. METHODS: A total of 53 consecutive H. pylori-infected patients (30 with proven ulcer disease, 23 with gastritis only) from a single center were prescribed two monocapsules q.i.d. after the three meals and after an evening snack during 10 days. Each capsule contained 60 mg colloidal bismuth subcitrate (as Bi2O3 equivalent), 125 mg tetracycline, and 125 mg metronidazole. Repeat endoscopy with biopsies for urease test, Giemsa stain, and culture was carried out ≥5 wk later. Side effect data were collected. RESULTS: One patient was lost to follow-up, two failed to respond, and 50 were cured. The intention-to-treat cure rate was 50 of 53 (94.4%, 95% CI 88.1–100%). Antibiotic sensitivity was available from 51 isolates. The cure rate in the metronidazole sensitive strains was 44 of 45 (97.8%, 95% CI: 93.5–100%), whereas it was four of five in the resistant strains. The regimen was well tolerated, with only two drop-outs (4%) because of side effects. CONCLUSIONS: The new monocapsule is an inexpensive, well tolerated, and patient-friendly formulation of a bismuth based triple therapy. A 10-day course with this multidrug capsule reached a very high cure rate in metronidazole-sensitive strains. The number of cases with resistant strains was insufficient to allow firm conclusions about its efficacy in case of resistance. The results are in agreement with previous data with bismuth triple therapy using separate drugs. From the high cure rate, we can conclude that the new capsule dissolves adequately, with proper delivery of its ingredients at the site of action.

A single drug for Helicobacter pylori infection: first results with a new bismuth triple monocapsule.

In this pilot study we investigated the efficacy and tolerability of a new monocapsule that contains a bismuth compound, tetracycline, and metronidazole. If proven to be effective, this monotherapy would turn the well-accepted multidrug regimen of standard bismuth-based triple therapy into an easy and more patient-friendly regimen. It can be used in patients allergic to penicillin. A total of 53 consecutive H. pylori-infected patients (30 with proven ulcer disease, 23 with gastritis only) from a single center were prescribed two monocapsules q.i.d. after the three meals and after an evening snack during 10 days. Each capsule contained 60 mg colloidal bismuth subcitrate (as Bi2O3 equivalent), 125 mg tetracycline, and 125 mg metronidazole. Repeat endoscopy with biopsies for urease test, Giemsa stain, and culture was carried out > or =5 wk later. Side effect data were collected. One patient was lost to follow-up, two failed to respond, and 50 were cured. The intention-to-treat cure rate was 50 of 53 (94.4%, 95% CI 88.1-100%). Antibiotic sensitivity was available from 51 isolates. The cure rate in the metronidazole sensitive strains was 44 of 45 (97.8%, 95% CI: 93.5-100%), whereas it was four of five in the resistant strains. The regimen was well tolerated, with only two drop-outs (4%) because of side effects. The new monocapsule is an inexpensive, well tolerated, and patient-friendly formulation of a bismuth based triple therapy. A 10-day course with this multidrug capsule reached a very high cure rate in metronidazole-sensitive strains. The number of cases with resistant strains was insufficient to allow firm conclusions about its efficacy in case of resistance. The results are in agreement with previous data with bismuth triple therapy using separate drugs. From the high cure rate, we can conclude that the new capsule dissolves adequately, with proper delivery of its ingredients at the site of action.

Re-treatment after Helicobacter pylori eradication failure.

Currently, highly effective Helicobacter pylori eradication therapies are used, and although eradication failures still appear in a considerable proportion of cases, the therapeutic efficacy in such refractory cases has been only exceptionally studied. Therefore, our aim was to evaluate the appropriate attitude when eradication therapy fails. In 127 duodenal ulcer patients, several therapies with omeprazole (O) plus one or two antibiotics [amoxycillin (A), clarithromycin (C), metronidazole (M)] had failed to eradicate H. pylori. Re-treatment was administered depending on initial therapy; in no case was the same regimen repeated, and antibiotics with resistance risk (as C or M) were only re-administered using combination regimens with bismuth (B): O + A + C + B (when C was re-administered) and O + bismuth triple therapy (BTT) (when M was re-administered). First therapy and eradication rates, with the corresponding second therapy, were: BTT re-treatment in O + A failure achieves a relatively low eradication rate, probably lower than BTT for the first time, suggesting that other regimens should be tried. The following re-treatments are recommended in H. pylori eradication failure: in O + A failure, BTT (or O + BTT, as BTT re-treatment could be less effective than the initial BTT treatment); in O + C failure, O + A + M; in O + A + C failure, O + BTT; in O + A + M failure, O + A + C; and, finally, in O + C + M failure, O + BTT (or O + A + C + B).

Bismuth triple therapy

Bismuth triple therapy (bismuth compound, metronidazole and tetracycline) is the oldest effective regimen to cure Helicobacter pylori infection. When tetracycline is replaced by amoxycillin the cure rate decreases. In 1990, it was the first-line regimen. However, the great number of pills in the rather complicated regimen, together with a relative high rate of side-effects, have stimulated the search for other regimens. In developed countries, it has now mainly been surpassed by the simpler, but much more expensive proton-pump inhibitor-based triple therapies. In many developing countries however, bismuth-based therapy is the only effective therapy patients can afford. Worldwide, this drug combination is therefore probably one of the most widely used regimens. The efficacy of bismuth triple therapy can be improved by adding acid suppressants (quadruple therapy), increasing treatment duration or increasing the total daily dose of metronidazole. The choice of the bismuth compound and the total daily dose of tetracycline seem less important. Treatment can be shorter (7 days) in areas with a low rate of metronidazole resistance or when acid inhibition is added. Bismuth is usually given four times daily; tetracycline is usually given 500 mg q.i.d. in a 7- or 10-day treatment, but this can probably be reduced to 250 mg q.i.d. in a 14-day regimen. A higher total daily dose of metronidazole increases the cure rate but also gives more side-effects. A daily dose of 1000-1200 mg metronidazole in three or four divided doses for one week suffices in areas with a low rate of metronidazole resistance. In areas with a higher rate of resistance one can either increase the treatment duration to 10-14 days or increase the daily dose of metronidazole to 1500-1600 mg and leave the treatment duration at 7 days.

Helicobacter Pylori.

All infected patients with a peptic ulcer should be treated for H. pylori. The role of treating H. pylori in patients with undiagnosed dyspepsia or non-ulcer dyspepsia, those taking nonsteroidal anti-inflammatory medications, or with a family history of gastric cancer remains controversial. Triple therapies consisting of a proton pump inhibitor or ranitidine bismuth citrate and two antibiotics are the current standard of therapy for H. pylori. In general, dual therapies should no longer be used to treat H. pylori. Bismuth triple therapy consisting of bismuth, tetracycline, and metronidazole is a less expensive alternative to proton pump inhibitor-or ranitidine bismuth citrate-based triple therapies. However, bismuth triple therapy is hampered by frequent side effects and the need for qid dosing. In Europe, a 7-day course of therapy appears to be adequate. In the United States, 10-14 days of therapy are currently recommended. Metronidazole resistance in H. pylori strains varies geographically, and negatively influences the effectiveness of therapies containing this antibiotic. Clarithromycin resistance is relatively infrequent at the current time but may be rising in countries where this antibiotic is in use. If a patient remains infected after a course of therapy for H. pylori, the second treatment should avoid the antibiotics used initially.

One-week ranitidine bismuth citrate versus colloidal bismuth subcitrate-based anti- Helicobacter triple therapy: a prospective randomized controlled trial

OBJECTIVE: The efficacy of 1 wk bismuth triple therapy is adversely influenced by the presence of metronidazole resistance. In vitro studies suggest that ranitidine bismuth citrate (RBC) plus metronidazole exhibit synergistic activity against metronidazole resistant strains of Helicobacter pylori ( H. pylori). Whether this confers a superior clinical efficacy remains unproven. This study compared the efficacy of RBC-based triple therapy with bismuth triple therapy in eradication of H. pylori. METHODS: Patients with H. pylori-related ulcer disease or gastritis were randomized to receive either 400/mg of RBC twice daily plus 400/mg of metronidazole and 500/mg of tetracycline four times daily for 1 wk (RMT) or 120/mg of colloidal bismuth subcitrate, 400/mg of metronidazole, and 500/mg of tetracycline, all given four times daily for 1 wk (BMT). Metronidazole susceptibility was determined by the E-test and pretreatment resistance was defined as minimum inhibitory concentration ≥32/mg/L. RESULTS: Of 100 consecutive patients randomized, two patients were lost to follow-up in each group. Forty-three of 85 (51%) H. pylori isolates were metronidazole resistant. Perprotocol cure rate for RMT and BMT was 40 of 41 (98%) and 37 of 44 (84%), respectively ( p = 0.058). Intent-to-treat cure rate for RMT and BMT was 46 of 50 and 41 of 50, respectively (92% vs 82%, p = 0.23). A significantly higher eradication of metronidazole resistant H. pylori was observed in the RMT group (25 of 25, 100%) than in the BMT group (12 of 16, 75%), ( p = 0.018). Side effects observed in the two treatment groups were comparable. CONCLUSIONS: One week of RBC triple therapy with metronidazole and tetracycline is an effective anti- Helicobacter therapy. This regimen is more appropriate in areas of high prevalence of metronidazole resistance.

Optimal treatment for duodenal ulcer disease: a cost-decision analysis in Malaysian patients.

The aim of the present study was to determine the cost-efficiency of different duodenal ulcer disease treatment practices in Malaysia. Six Malaysian gastroenterologists met to discuss the direct costs related to Helicobacter pylori (HP) eradication treatment. Five treatment strategies were compared: (i) histamine H2 receptor antagonists (H2RA), acid suppression therapy for 6 weeks followed by maintenance therapy as needed; (ii) bismuth triple + proton pump inhibitor (PPI), bismuth (120 mg, q.i.d.), metronidazole (400 mg; t.i.d.), tetracycline (500 mg, q.i.d.) for 7 days and PPI, b.i.d., for 7 days; (iii) OAC, omeprazole (20 mg, b.i.d.), amoxycillin (1000 mg, b.i.d.) and clarithromycin (500 mg, b.i.d.) for 7 days; (iv) OMC, omeprazole (20mg, b.i.d.), metronidazole (400mg, b.i.d.) and clarithromycin (500 mg, b.i.d.) for 7 days; and (v) OAM, omeprazole (20 mg, b.i.d.), amoxycillin (1000 mg, b.i.d.) and metronidazole (400 mg, b.i.d.) for 7 days. A decision tree model was created to determine which therapy would be the most cost-effective. The model considered eradication rates, resistance to anti-microbial agents, compliance and cost implications of treatment regimens, physician visits and ulcer recurrences during a 1 year time period assumption. The H2RA maintenance therapy was the most expensive treatment at Malaysian Ringgit (MR) 2335, followed by bismuth triple therapy (MR 1839), OMC (MR 1786), OAM (MR 1775) and OAC, being the most cost-effective therapy, at MR 1679. In conclusion, HP eradication therapy is superior to H2RA maintenance therapy in the treatment of duodenal ulcer disease. Of the HP eradication regimens, OAC is the most cost-effective.

Recurrence of Helicobacter pylori infection after eradication: Incidence and variables influencing it

Background: Our aim was to study the incidence of Helicobacter pylori recurrence in our country and to assess the different variables that might influence it. Methods: We studied prospectively 331 duodenal ulcer patients (mean age, 48_14 years, 71% male) in whom H. pylori had been eradicated. Several therapies were used, classified as low-efficacy (omeprazoleamoxycillin, 32% eradication rate; omeprazole_amoxycillin_metronidazole, 56%) and high-efficacy therapies (omeprazole_clarithromycin_ amoxycillin or metronidazole, 88%; bismuth triple therapy, 77%). One month after completion of therapy an endoscopy with biopsies and/or 13C-urea breath test was performed. A breath test was carried out again at 6 months, 1 year, and 2 years, to study H. pylori recurrences. Endoscopy (with biopsies) was performed only to confirm recurrences. Multiple logistic regression analysis was used. Differences between Kaplan-Meier curves were evaluated with the log-rank test. Results: Sixty-seven patients were followed up for 6 m...

The effect of metronidazole and clarithromycin resistance upon 7-day triple therapy of H. pylori infections in patients with duodenal ulcer in Korea

Triple therapy regimens containing metronidazole (MET) or clarithromycin (CL) have been used for the treatment of 11. pylori (Hp). An increase in prevalence of MET resistance (MET R) has been reported worldwide and there are some reports about the decline of its efficacy due to the resistance in Hp eradication. The purpose of this study is to investigate the prevalence of MET R and CL resistance (CL R) before treatment, and to examine the effect of MET R and CL R upon Hp eradication rate of two kinds of 7-day triple therapy. A total 52 different Hp strains collected from Korean patients with duodenal ulcer (DU) were tested for sensitivity against MET and CL. Antibiotic sensitivity test was conducted by broth dilution method for MET R and by Etest and disk diffusion test for CL R. Fifty-two DU patients were randomized to receive two types of 7-day triple therapy: one includes colloidal bismuth subcitrate 120mg, metronidazole 250mg and tetracycline 500mg, each of which was taken four times daily, and the other includes omeprazole 20mg once a day, amoxicillin 1.0g and clarithromycin 500mg twice a day. Eradication rate was determined according to the Hp tests CLOtest, Giemsa stain, Gram stain of touch print, and culture in the antrum and in the corpus of stomach at least 4 weeks after triple therapy. The breakpoint MIC used for MET R was > 8 p g/ml and for CL R _> 2 la g/ml. The rates of MET R and CL R were 76.9% and 5.8%, respectively. The eradication rate of bismuth-triple therapy was 100% for MET sensitive strains and 75% for MET resistant strains, which are taken together to yield the overall rate of 88.0%. The eradication rate of omeprazole-triple therapy was 90.0% for CL sensitive strains and 33.3% for CL resistant, both of which together give the overall rate of 85.2%. From these results, we found that the prevalence of metronidazole resistance is much higher than that of clarithromycin in Korea, but the metronidazole resistance turns out to be less significant than that of clarithromycin in the eradication of Hp. This research was sponsored by Non-Directed Research Fund, Korea Research Foundation.

New, improved Helicobacter pylori eradication therapy in children.

New, improved Helicobacter pylori eradication therapy in children.

Ulcers and gastritis.

Once again this year, developments in the field of ulcers and gastritis have been entirely dominated by findings relating to Helicobacter pylori. However, interest in H. pylori can be expected to decline, since the prevalence of the infection is rapidly decreasing in the developing world - to the point that many gastroduodenal ulcers are now unrelated to H. pylori A further reason for declining interest is disappointment regarding the role of H. pylori in dyspepsia. The expected reduction in the endoscopic workload produced by screening for H. pylori or cagA positivity has so far not occurred. The exact role of the damage caused by nonsteroidal anti-inflammatory drugs in H. pylori-infected stomachs remains controversial. Equally controversial is the magnitude of the increased reflux symptomatology and reflux disease observed after H. pylori infection has been cured in patients with ulcer disease. Eradication therapy is largely dominated by proton-pump inhibitor triple therapies, although the efficacy of these is declining. Bismuth triple therapy and quadruple therapy continue to be valid alternatives.

Simplified 10-day bismuth triple therapy for cure of Helicobacter pylori infection: experience from clinical practice in a population with a high frequency of metronidazole resistance.

To evaluate the cure rate of Helicobacter pylori infection, including the impact of in vitro metronidazole resistance (M-R), and the side effects of a simplified 10-day bismuth triple therapy in routine clinical practice. From September 1995 to March 1996, 248 consecutive H. pylori-positive patients received 10 days of bismuth subnitrate 150 mg, oxytetracycline 500 mg, and metronidazole 400 mg, all t.id. Before treatment, upper endoscopy, including biopsy specimens for microbiological analysis and IgG serology were performed. M-R was found in 45% of females and 36% of males. At least 2 months after treatment, H. pylori status was assessed by the 14C urea breath test (n = 131), endoscopy (n = 37), urea breath test and endoscopy (n = 63), or solely by IgG serology (n = 7). Ten patients withdrew. IgG serology was performed again after 1 yr. H. pylori infection was cured in 205 patients: 86% by all-patients-treated analysis and 83% by intention-to-treat analysis. When patients were classified according to pretreatment metronidazole susceptibility, cure of infection was achieved in 76% of females harboring M-R strains versus 96% of those with sensitive strains (p = 0.002) and in 81% versus 88% (p = 0.34) of males with M-R versus sensitive strains, respectively. Twelve patients (5 %) had to stop treatment prematurely because of severe side effects, but eight of them were treated successfully. One case of H. pylori infection (0.6 %) was detected at 1-yr follow-up. Ten-day bismuth triple therapy t.i.d. was effective in curing H. pylori infection in the context of routine clinical practice. The efficacy was reduced in females harboring M-R strains.

Simplified 10-day bismuth triple therapy for cure of Helicobacter pylori infection: Experience from clinical practice in a population with a high frequency of metronidazole resistance

Simplified 10-day bismuth triple therapy for cure of Helicobacter pylori infection: Experience from clinical practice in a population with a high frequency of metronidazole resistance