Maastricht recommendations effective for HP eradication

Clinical Question

How effective are the proposed guidelines for H. pylori eradication from the Maastricht III conference?

Bottom Line

A sequence of 3 strategies was successful in eradicating H. pylori in 89% of patients by intention-to-treat analysis and in 98% of patients by per-protocol analysis. (LOE = 2b)

Reference

Rokkas T, Sechopoulos P, Robotis I, Margantinis G, Pistiolas D. Cumulative H. pylori eradication rates in clinical practice by adopting first and second-line regimens proposed by the Maastricht III Consensus and a third-line empirical regimen. Am J Gastroenterol 2009;104(1):21-25.  [PMID:19098844]

Study Design

Cohort (prospective)

Funding

Self-funded or unfunded

Setting

Outpatient (any)

Synopsis

There are dozens of proposed regimens for the eradication of H. pylori. A recent consensus conference reviewed the literature and recommended that the first-line regimen was a proton pump inhibitor (PPI), amoxicillin 1 g twice daily, and clarithromycin 500 mg twice daily for 10 days as long the resistance to clarithromycin was less than 20%. The recommended second-line therapy (if the first-line therapy was ineffective or contraindicated) was a PPI, bismuth 300 mg 4 times daily, metronidazole 500 mg 3 times daily, and tetracycline 500 mg twice daily for 10 days. After 2 treatment failures, the guidelines recommend gastric biopsy and culture. In this study, the authors applied first-line therapy to 540 consecutive patients positive for H. pylori. They had a 70% eradication rate using intention-to-treat analysis and a 76% eradication rate using per-protocol analysis. The 120 treatment failures were given second-line therapy, with 69% intention-to-treat and 73% per-protocol eradication rates. At this point, 30 patients of the original 540 were not withdrawn or lost to follow-up (n = 47) and still had persistent infection. The authors felt that biopsy was too invasive and these patients were instead given a third-line therapy with a PPI, amoxicillin 1 g twice daily, and levofloxacin 500 mg twice daily for 10 days. This regimen was successful in 21 of these patients for a 70% eradication rate by both analyses.