A practical approach to patients with refractory Helicobacter pylori infection, or who are re-infected after standard therapy.

The vast majority of recurrences of Helicobacter pylori infection after apparent eradication are observed during the first year. Almost all of these early recurrences are due to recrudescence rather than reinfection by a new strain. After the first year, the recurrence rates approximate to the rate of natural acquisition of H. pylori infection. By contrast, in developing countries, higher rates of recurrence suggest a major role of real reinfection. Important predictive factors of H. pylori treatment success are compliance and bacterial susceptibility to antibiotics. The new 1-week triple therapies, based on a proton pump inhibitor (PPI) and 2 antibiotics, lead to treatment discontinuation but rarely. If containing a nitroimidazole, their efficacy is reduced to 60 to 80% by pretreatment in vitro resistance. The prevalence of nitroimidazole resistance varies dependent on the geographical area, with rates over 50% in tropical regions. Resistance against macrolides hinders treatment success in 50 to 80% of patients. In the US, south-western Europe and Japan the prevalence of macrolide resistance amounts to about 10%, in other countries about 3%. After failed treatment, acquired resistance is frequent. Testing for resistance is recommended to facilitate the decision for an alternative triple therapy or for quadruple therapy comprising bismuth, metronidazole, tetracycline and a PPI. It seems reasonable to increase the dose of PPI in a retreatment regimen containing amoxicillin. Post-treatment double resistance against nitroimidazoles and macrolides reduces the success of most of the currently evaluated retreatment regimens. To overcome double resistance, high dose PPI plus amoxicillin is one approach, beside other experimental multidrug treatments.