Response to: Treatment prolongation or quadruple therapy:- Individualization by geographical region.

Sir,

We read with interest the letter by Losurdo et al., which brings to attention a relevant issue regarding the poor response to 10-day sequential therapy (S10) in case of clarithromycin resistance (70.1% to 10%) compared with clarithromycin-susceptible strains (74.1% to 33.3%) in 14-day triple (T14) therapy arm.[12] There was no clear reason behind this finding. However, as stated by the authors, the total number of strains resistant to clarithromycin in our study was low in both arms (10 in S10, and 3 in T14) and hence, the difficulty in obtaining concrete conclusions. Another possibility is that prolonged therapy with clarithromycin (14 days in T14 group rather than 10 days in S10 group) may theoretically help in overcoming the resistance to clarithromycin.

As outlined in our study, the rate of resistance to antimicrobials was high and this may be due to the “unfortunate” open access policy to antibiotics prescriptions in Saudi Arabia, reflecting the high resistance rate of Helicobacter pylori to metronidazole (48.5%), clarithromycin (23.3%), amoxicillin (14.8%), and levofloxacin (11.1%). The very low level of tetracycline prescriptions, and unavailability of this antimicrobial in most of the pharmacies, has resulted in a low resistance rate of 2.3%.[2]

According to the Maastricht IV/Florence Consensus Report, the choice of firstline regimen in a given country should be driven by the local prevalence of H. pylori strains with clarithromycin resistance. Clarithromycin-containing triple therapy without prior susceptibility testing should be abandoned when the clarithromycin resistance rate in the region is more than 15%–20%. In the upcoming Maastricht V Consensus Report, a threshold of 15% has been recommended to define countries with high clarithromycin resistance rates, and consequently forsake clarithromycin-containing regimens such as triple and sequential therapies.[3]

We believe that the eradication rate of H. pylori can be optimized when treatment is prolonged to 14 rather than 7–10 days. However, adherence is a major challenge and most patients will not take the prescribed medications for more than 10 days. Given the high prevalence rate of clarithromycin resistance in our country, the best option for our patients would be either quadruple therapy or concomitant therapy with or without probiotics.[45]

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Conflicts of interest

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