Response to: Comment on "Efficacy of 7-Day and 14-Day Triple Therapy Regimens for the Eradication of Helicobacter pylori: A Comparative Study in a Cohort of Romanian Patients".

In a recent Letter to the Editor [1], Talebi Bezmin Abadi commented on the paper by Arama et al. [2], in which the authors concluded that a 2-week regimen (Proton Pump inhibitor, plus Clarithromycin plus Amoxicillin) is preferable to a 7-day regimen as first-line therapy for Helicobacter pylori (H. pylori) infection. In his Letter, Talebi Bezmin Abadi concluded that “Certainly, preantibiotic susceptibility tests are inevitable approach in H. pylori therapy.” Although we agree with all comments, we found the conclusion inappropriate.

The 4th Maastricht/Florence Consensus Conference recommended abandoning clarithromycin in empirical treatment when the prevalence of resistance is higher than 15–20% [3].

In the paper by Arama et al. [2], the overall eradication rate observed was 70.5%: the number of patients who responded to treatment was significantly greater in the 14-day treatment (84.6%) group compared to patients who received the 7-day treatment (42.3%) (p < 0.001).

An acceptable eradication rate is differently defined in literature (>75% [4], ≥ 90–95% [5]) and the clinicians should “use only what works locally” ignoring consensus statements and society guidelines if these are not consistent with local treatment results [6]. Moreover, antibiotic resistance should be considered as a dynamic concept, since its prevalence can change not only among different countries, but also between two different periods in the same area [7].

A culture-based approach, in clinical practice, is often unfeasible and its cost may be hard to afford [8]. Furthermore, the whole process needs a standard of quality (in terms of both materials used for culture and skill of the microbiologist to grow H. pylori) that cannot be assured everywhere [7]. Probably, the cost-effectiveness of the culture-based approach may change depending on host-related factors (bleeding, use of certain drugs) and methodology-related factors (number of gastric biopsies, conditions of transport, and laboratory characteristics) [7]. These factors may be favorable in some settings compared to others.

Hence, in the year 2016 a culture-guided treatment must be taken into account only in settings with experience in this issue and after failure of previous regimens.