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Helicobacter pylori treatment in the era of increasing antibiotic resistance
  1. David Y Graham1,
  2. Lori Fischbach2
  1. 1Department of Medicine, Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
  2. 2University of North Texas Health Science Center School of Public Health, Fort Worth, Texas, USA
  1. Correspondence to David Y Graham, Michael E DeBakey Veterans Affairs Medical Center, RM 3A-320 (111D), 2002 Holcombe Boulevard, Houston, TX 77030 USA; dgraham{at}


With few exceptions, the most commonly recommended triple Helicobacter pylori regimen (proton pump inhibitor (PPI), amoxicillin and clarithromycin) now provides unacceptably low treatment success. A review of worldwide results suggests that successful eradication using a triple regimen is not consistently observed in any population. Clinicians should use ‘only use what works locally’ and ignore consensus statements and society guidelines if they are not consistent with local results. Clinical trials should be result based, with the goal of identifying regimens with >90–95% success. New treatments should be only be compared with the currently locally effective treatment (>90%) or a historical untreated control (which has been shown to reliably yield 0% eradication); trials using placebos or treatments known to be inferior are with rare exceptions unethical. If a highly effective regimen is not available locally, we recommend trying a 14 day concomitant quadruple treatment regimen containing a PPI, amoxicillin, clarithromycin and a nitroimidazole; 10 day sequential treatment (PPI plus amoxicillin for 5 days followed by a PPI, clarithromycin and a nitroimidazole for 5 days); or 14 day bismuth-containing quadruple treatments. Treatments needing further evaluation include those containing furazolidone or nitazoxanide, hybrids of sequential–concomitant therapies and amoxicillin–PPI dual therapy with PPI doses such that they maintain intragastric pH >6.

  • Antibiotics
  • antibiotic treatment
  • amoxicillin
  • clarithromycin
  • eradication treatment
  • Helicobacter pylori
  • metronidazole
  • proton pump inhibitors
  • tetracycline

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  • Funding Public Health Service grant DK56338.

  • Competing interests In the last 2 years, Dr Graham has received 20 free urea breath tests from Meretek. Dr Graham is a consultant for Novartis in relation to vaccine development for treatment or prevention of H. pylori infection. Dr Graham is also a paid consultant for Otsuka Pharmaceuticals and until July 2007 was a member of the Board of Directors of Meretek, Diagnostics, the manufacturer of the 13C-urea breath test. Until November 2009, Dr Graham received royalties on the Baylor College of Medicine patent covering materials related to 13C-urea breath test. Dr Fischbach declares no competing interests.

  • Provenance and peer review Commissioned; externally peer reviewed.

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