Is there a need?

Antibiotic-based triple therapy is reasonably effective in treating patients with symptomatic Helicobacter pyloriinfection, but this approach is untenable for global control of the infection. In practice, however, anti-H pylori therapy is prescribed to an increasing number of patients, in the absence of proven benefit.1 ,2 Firstly, anti-H pyloritreatment is increasingly offered to infected patients with non-ulcer dyspepsia and to asymptomatic carriers. This “test-and-treat” attitude is aimed at controlling the dyspeptic symptoms and at reducing long term risk of gastric malignancies in infected individuals. Secondly, anti-H pylori treatment is also advocated as a first approach in H pylori positive dyspeptic patients, in an attempt to reduce the overall management costs of these patients, without prior endoscopic documentation of the presence of an ulcer or of other complications of the infection.3 ,4 Even though some decision analysis and clinical studies suggest that these different approaches may be beneficial,3-5 other studies have failed to show potential benefit.6-8

The increased prescription of antibiotics for H pyloriinfection has encouraged the emergence of antibiotic resistant strains. Indeed, the efficacy of current therapies rarely exceeds 90%, and strains isolated after treatment failure often show resistance.9 Resistance to metronidazole is already high in developed countries, and resistance to clarithromycin is increasingly evident. A survey of resistance conducted over five years in Ireland showed that resistance to metronidazole and clarithromycin increased from 32% to 46% and from 5.3% to 8.6%, respectively.10 Because metronidazole has been available for decades before being used against H pylori, this rapid evolution suggests that the selection pressure on H pylorideveloped once antibiotics were prescribed in association with antisecretory agents. If this speculation is correct, the number of patients treated for H pylori infection may impact directly on the …