Therapeutic options after failed Helicobacter pylori eradication therapy

OBJECTIVES: Many of the currently used Helicobacter pylori eradication regimens fail to cure 5-20% of the patients. Those patients will remain at risk of developing a potentially fatal complication of peptic ulcer disease. Therefore, a new attempt to cure H. pylori infection after initial failure of therapy is indicated. We studied the efficacy of three retreatment regimens after initial failure of omeprazole-amoxicillin dual therapy. METHODS: Fifty-three patients whose treatment failed were randomly assigned to receive retreatment with the same regimen of omeprazole 20 mg b.i.d. (group I) or omeprazole 40 mg t.i.d. (group II) plus amoxicillin 750 mg t.i.d. for 14 days. Forty patients in whom the omeprazole-amoxicillin retreatment failed were assigned to receive omeprazole 20 mg b.i.d., amoxicillin 750 mg t.i.d., and metronidazole 500 mg t.i.d. for 14 days (group III) or omeprazole 20 mg b.i.d. plus clarithromycin 500 mg t.i.d. for 14 days (group IV). H. pylori infection was assessed by culture and histology of gastric biopsies before and 4-6 wk after cessation of therapy. Susceptibility of H. pylori to amoxicillin, clarithromycin, and metronidazole was determined by the E test. RESULTS: In groups I (n = 28) and II (n = 25), cure of H. pylori infection was achieved in 21% and 28% of patients, respectively (not significant). In groups III (n = 20) and IV (n = 20), H. pylori infection was cured in 75% and 70%, respectively. CONCLUSIONS: Retreatment with an identical omeprazole-amoxicillin dual regimen is of limited benefit, a result that is independent of the omeprazole dose. In contrast, a third H. pylori eradication attempt with omeprazole-clarithromycin dual therapy or omeprazole-amoxicillin-metronidazole triple therapy provides reasonable cure rates after failure of omeprazole-amoxicillin dual therapy