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How do you approach resistant Helicobacter pylori?

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How do you approach resistant Helicobacter pylori?

There are a number of accepted first line treatment combinations for H. pylori eradication.  A regime of a PPI + Amoxycillin + Clarithromycin for 7 – 14 days is the most commonly used.  For patients allergic to penicillin a cephalosporin, metronidazole or tetracycline can be substituted.  There is now a high level of metronidazole resistance.

It is critical to discuss treatment carefully with the patient.  They must clearly understand the risks including allergic reactions and C.difficile induced pseudomembranous colitis.  They need to understand treatment eradication success rates and realize missing any medication dose will seriously increase the likelihood of treatment failure.

If first-line therapy has failed, consider possible reasons.  Has the patient taken ALL OF EVERY medication prescribed?  If side effects have caused compliance failure, then further treatments containing the drug causing the side effects will also fail.

Are further attempts at eradication justified?  Patients presenting with MALT lymphoma, family history of gastric carcinoma, current or a past history of peptic ulcer, the need for long term PPI therapy, and requirement for blood thinning or longterm NSAID use certainly require eradication.  An elderly person with none of the above does not.  C.difficile infection can be a devastating illness in the elderly.  This risk outweighs likely benefits in older patients without major risk factors.  It is often useful to outline side effects and success rates of further attempts versus risks of non eradication and let the patient decide.

If there are compelling reasons to eradicate, then it is often best to go straight to the more expensive and (for the doctor!) tedious third line treatment.  Unfortunately these drugs have to be obtained through the TGA Special Access Scheme.

You will need:

  • TGA Category B Special Access Form (Phone Tri-med 08 9388 1444)
  • Complete form and send to TGA
  • TGA will send you a letter; send this to Tri-med with payment.  Treatment is DENOL + FURAZOLIDONE + AMOXYCILLIN