Before it was known that Helicobacter pylori causes gastritis, Helicobacter pylori infections were treated with drugs that neutralize stomach acid (antacids) and gastric acid inhibitors (proton pump inhibitors). Current treatment of Helicobacter pylori infection requires detection of the pathogen and includes treatment/eradication with three drugs taken at the same time. Two antibiotics and a proton pump inhibitor are combined, which inhibits the release of gastric acid and thus makes the survival of Helicobacter pylori in the stomach much more difficult.
This is necessary to fight the germ and not just treat the symptoms as before. The Maastricht Consensus criteria, revised in 2005, prescribe the indications for the elimination (eradication) of the pathogen in a Helicobacter pylori infection. A distinction is made between confirmed and recommended indications.
Secured indications are thus a gastric or duodenal ulcer, atrophic gastritis or MALT-lymphoma. Also Helicobacter pylori infected patients with partial gastric resection due to gastric cancer or peptic ulcer and patients in whom a first-degree relative has developed gastric cancer are recommended to undergo Helicobacter pylori eradication with the antibiotic treatment described above for eradication. In contrast, there are advisable indications such as functional dyspepsia, gastrooesophageal reflux disease and prolonged use of non-steroidal anti-inflammatory drugs such as diclofenac or ibuprofen.
Eradication with only one antibiotic (monotherapy) does not achieve sufficient success in fighting the germ. Triple therapy, on the other hand, leads in almost all cases to the eradication of the germ. There are different regimes according to which the drugs are administered.
Common to all is a seven-day application of 3 capsules in the morning and evening. The French triple therapy of eradication consists of The treatment usually responds well and the eradication rate is high. In the Italian triple therapy, the difference is the administration of metronidazole (Clont®) instead of amoxicillin.
Since amoxicillin is a penicillin antibiotic and up to 10% of the population has a penicillin allergy, the Italian therapy is desirable for those affected. However, there are Helicobacter pylori strains that are resistant to metronidazole. The English therapy, which combines metronidazole and amoxicillin as antibiotics, only eliminates about 70-80% of the germs.
Further combination options are currently being tested and in some studies have already achieved even better eradication results than the previous ones. However, in order to be able to recommend them as a primary therapy option, further reports on experience are awaited. If eradication fails, the pathogen must be cultivated and resistance to antibiotics must be ruled out.
In case of failure of triple therapy due to lack of cultivation of the pathogen, there is the possibility of quadruple therapy. In this case, a proton pump inhibitor is combined with the antibiotics tetracycline and metronidazole, as well as a bismuth salt over a period of ten days. Other antibiotics such as rifabutin or levofloxacin can also be given as an alternative, sometimes for a longer period of time.
However, these saving treatments (= Rescuetherapy) are exceptions and mainly recommended for patients with failed standard triple therapy or resistance to antibiotics.
- Amoxicillin or Metronidazole
- Clarithromycin.
- The proton pump inhibitor Pantoprazole in combination
- With the antibiotics amoxicillin
- And Clarithromycin.
There are guidelines for Helicobacter pylori eradication based on the recommendations of the Association of the Scientific Medical Societies in Germany (AWMF). Such guidelines exist for the diagnosis and therapy of many diseases.
They serve as a guide for physicians, but are not legally binding. They are based on the results of scientific studies and are intended to ensure greater safety in medicine, but also take economic aspects into account.The guidelines for Helicobacter pylori eradication are an updated version of the recommendations issued by the German Society for Digestive and Metabolic Diseases (DGVS) in 1996. The current guidelines have been agreed upon by the German Society for Hygiene and Microbiology, the Society for Pediatric Gastroenterology and Nutrition and the German Society for Rheumatology.
On the one hand, the guidelines state which tests can be used to make a reliable diagnosis. Recommended tests include the urease rapid test, cultural cultivation of the bacterium and microscopic detection. The urea breath test, the detection of antigens in stool or antibodies in blood are also possible tests.
On the other hand, the guidelines for Helicobacter pylori eradication contain the findings that must be present in a patient in order to perform eradication as a recommended therapy. These include, for example, a peptic ulcer (peptic ulcer ventriuli), asymptomatic Helicobacter pylori gastritis and stomach cancer (gastric carcinoma). Depending on the severity of the disease, the guidelines state whether eradication is recommended or not and what the requirements for eradication are, i.e. what test results should be available to initiate therapy.
The recommendations for the drugs that are recommended can also be found in the guidelines. Also included there are the suggestions for second-line therapy, which is started when first-line therapy is not effective or when patients cannot tolerate it. It is also recommended that a review of the success of eradication should be carried out and that this should take place at least four weeks after the end of antibiotic therapy.
