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Treatment after failure: the problem of “non-responders”
  1. J-Q Huang,
  2. R H Hunt
  1. Division of Gastroenterology, McMaster University Medical Centre, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5
  1. Professor Hunt.

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Summary

Although the currently most effective treatment regimens cure about 90% of infections, 10% of patients remainHelicobacter pylori positive. Several factors contribute to treatment failure. These include patient compliance, bacterial resistance to antibiotics, and treatment related issues. Treatment failure leads to the development of bacterial resistance to metronidazole and clarithromycin. Retreatment can be undertaken after considering several different strategies: to repeat the same regimen with full doses of medications and a longer treatment duration, or to choose different regimens to avoid the antibiotic previously used, or to switch to proton pump inhibitor (PPI) based quadruple therapy or ranitidine bismuth citrate (RBC) based triple therapy. In principle, full doses and longer treatment durations are advisable. As retreatment is always difficult, choosing the best available first line treatment regimen is still the best “rescue” treatment.

It has been over 12 years since the first randomised, placebo controlled clinical trial for the eradication of H pylori infection was published.1 Treatment to eradicate the infection has evolved from single agents to multiple combination treatments consisting of an antisecretory agent and one or more antibiotics.2 ,3 Treatments that achieve an eradication rate of greater than 80%, on an intent to treat basis, have been recommended by most consensus conferences and authorities.4-7 These now include bismuth based triple therapy, triple therapy involving a PPI and two antibiotics, quadruple therapy, or more recently combinations with RBC and two antibiotics. Although these combination treatments are very effective for eradicating H pylori infection in most patients, a significant proportion of patients fail these treatments for a variety of different reasons such as bacterial resistance, poor compliance, or treatment related factors.8 ,9 Retreatment of these non-responders remains a challenging issue as some patients may need more than two attempts for eradication of the infection. …

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