Helicobacter pylori eradication in clinical practice: retreatment rates and costs of competing regimens

Helicobacter pylori and dyspepsia: physicians' attitudes, clinical practice, and prescribing habits

BACKGROUND

Consensus guidelines have been published on the management of Helicobacter pylori infection and it is assumed that these guidelines are adhered to in clinical practice.

AIM

To assess the changing attitudes of medical practitioners to H. pylori, and the impact of H. pylori infection on everyday clinical practice and prescribing patterns.

METHODS

Data for this review were gathered up to December 2000 from detailed review of medical journals, the biomedical database MEDLINE, and relevant abstracts.

RESULTS

Physician surveys show widespread acceptance of H. pylori as a causal agent in peptic ulcer disease. Gastroenterologists adopted H. pylori therapy for peptic ulcer earlier and more comprehensively than primary care physicians. Despite a low level of belief in H. pylori as a causal agent in non-ulcer dyspepsia and gastro-oesophageal reflux disease (GERD), H. pylori therapy is widely prescribed for these conditions. Proton pump inhibitor-based triple therapy is the eradication regimen of choice by all physician groups. In routine clinical practice, there appears to be significant under-treatment of peptic ulcer disease with H. pylori therapy, but extensive use for non-ulcer indications. Prescription of H. pylori treatment regimens of doubtful efficacy appears commonplace, and are more likely in primary care. Despite the advent of H. pylori therapy, the prescription of antisecretory therapy, particularly of proton pump inhibitors, continues to rise.

CONCLUSIONS

Publication of consensus guidelines per se is not enough to ensure optimal management of H. pylori infection. Innovative and ongoing educational measures are needed to encourage best practice in relation to H. pylori infection. These measures might be best directed at primary care, where the majority of dyspepsia is managed.

Treatment of Helicobacter pylori

Helicobacter pylori causes several gastroduodenal diseases. Various antibiotic regimens are available that eradicate H. pylori in 80 to 90% of patients, but no regimen cures all patients. Dual therapy is now obsolete. Triple therapy with two antibiotics and either a proton pump inhibitor or bismuth is the regimens of choice. Metronidazole and clarithromycin are the two key antibiotics. Antibiotic resistance against these two drugs is becoming more problematic and should be taken into consideration when choosing a regimen. Antibiotic resistance is usually induced after failure. Quadruple therapy has been used as a salvage regimen in failed cases but it is also the most complicated regimen. Several new agents are being studied including a single capsule that contains bismuth, metronidazole, and tetracycline.