H.pylori Eradication

H.pylori is an infection of the stomach lining usually acquired in childhood and carried by approximately a third of the World’s population. It may cause gastric inflammation, gastritis, gastric and, or duodenal ulceration and is recognised as the most significant causative agent in both gastric cancer and gastric lymphoma. There are also associations with a number of other systemic diseases. For these reasons and in patients who have the above diagnoses or symptoms of dyspepsia testing for H.pylori, either in stool or blood tests or at the time of endoscopy (CLO testing) is often undertaken and treatment to eradicate H.pylori is often recommended.

Treatment usually consist of a combination of antibiotics and proton pump inhibitors taken regularly for a period of 7 to 14 days. Common adult regimes include amoxycillin 1g twice daily, metronidazole 400mg, twice daily and either omeprazole 20mg twice daily or lansoprazole 30mg twice daily for 10 days, followed by 3 further weeks of once daily full dose (20mg omeprazole or 30mg lansoprazole) proton pump inhibitor. In areas where metronidazole resistance is common  clarithromycin is often used in place of metronidazole. In those with penicillin allergy  amoxycillin may be replaced by clarithromycin. A number other treatment regimes are available. Whilst more prolonged use of the antibiotic component of the treatment increases treatment efficacy (the likelihood of getting rid of H. pylori, longer courses of antibiotics have a greater risk of side effects such as antibiotic associated diarrhoea. If first line treatment fails as it does in approximately 20-30% of patients second line therapy should be considered. This usually constitutes tetracycline, metronidazole, bismuth citrate and a proton pump inhibitor. Alternatively a combination of PPI, amoxycillin and levofloxacin may also be appropriate.  If at this stage H. pylori persists then current European guidance suggests culture of organisms from the stomach and subsequent testing to assess their sensitivities to specific antibiotics may be appropriate.