Helicobacter Treatment

Effective Helicobacter eradication therapy:

• Levofloxacin triple therapy
• Rifabutin triple therapy
• Bismuth based quadruple therapy
• Novel tailored regimens
• Treatments for patients with penicillin allergy including arrangement of penicillin allergy testing when appropriate
• Endoscopy to look for and monitor complications of infection

A 40 year old woman presented with Helicobcater infection refractory to two courses of first line therapy. She had been diagnosed on a Urease breath test to investigate symptoms of bloating and burning epigastric pain with a background family history of stomach cancer. Her initial treatments were with metronidazole (flagyl) substituted for amoxicillin due to a remote history of penicillin allergy. At endoscopy we found moderate active gastritis with plentiful Helicobcater organisms and treated her with a bismuth based quadruple therapy that did not contain penicillin, but unfortunately this was unsuccessful. Because the majority of other treatments require amoxicillin, we arranged for penicillin allergy testing through Westmead hospital, which ultimately showed that she did not have a true allergy. She was treated with Rifabutin triple therapy and the Helicobcater was eradicated.

Up to 20% of people in Western countries such as Australia are infected with Helicobcater at some point in their life, in some countries over 50% of the population is affected. It is thought Helicobcater is acquired mainly in childhood via close family contacts, primarily via Saliva or faeces. Domestic cats and primates may also be a source of infection.

Everyone who is infected will get some degree of Gastritis (stomach inflammation), but symptoms and significant complications are variable.

The most important complications of Helicobacter infection are:

• Peptic Ulcer Disease (Gastric and/or Duodenal Ulcers)
• Atrophic gastritis with intestinal metaplasia
• Gastric cancer
• MALT lymphoma

High Priority for testing and treatment:

• Patients with established complications such as Gastric or Duodenal Ulcer, Atrophic gastritis, Gastric cancer or MALT lymphoma

Good reasons for testing and treatment:

• Patients with Dyspepsia (upper abdominal pain, bloating etc)
• Where there is a strong family history of Peptic Ulcer disease or Gastric Cancer
• Prior to long term use of anti-inflammatory drugs like Aspirin, Ibuprofen, Voltaren, Mobic etc.
• Patients with persistent bad breath (halitosis), chronic urticaria or ITP where standard causes have been excluded

Less good reasons for testing and treatment:

• Patients with Reflux (eradication may make the symptoms worse)
• As a primary risk reduction strategy

Helicobcater can be diagnosed on a blood test, via breath test, faecal test or endoscopy. Breath tests are very reliable and show evidence of current active infection. Faecal tests are best for kids as they are not exposed to the tiny amount of radiation used in a breath test. Blood tests show exposure to Helicobactre, but can remain positive even after eradication. Endoscopy is important for documenting the complications of infection and is the gold standard for diagnosis.

1st line

• 7 day triple therapy of Amoxycillin, Clarithromycin and Proton Pump Inhibitor (Nexium Hp7 pack)
• Metronidazole is substituted for amoxicillin in patients with a penicillin allergy
• Other options are available for patients who find these treatments make them sick

2nd line

• Levofloxacin triple therapy
• Rifabutin triple therapy

3rd line and beyond

• Bismuth based quadruple therapy
• Novel tailored regimens

Most eradication regimens have a success rate between 65-85%, with the chance of getting rid of Helicobacter reducing with each successive treatment.

Reasons for treatment failure include:

• Antibiotic resistance
• Smoking (reduces rate by 20%)
• Compliance (not taking the full treatment course)