Fax +41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Stomach Dig Dis 2007;25:203–205 DOI: 10.1159/000103885 How to Proceed in Helicobacter pylori -Positive Chronic Gastritis Refractory to First- and Second-Line Eradication Therapy Dino Vaira a Chiara Ricci b Alberto Lanzini b Federico Perna a Antonio Romano a Roberto Corinaldesi a a Department of Internal Medicine and Gastroenterology, University of Bologna, Bologna, and b Gastroenterology Unit, University of Brescia, Brescia, Italy Helicobacter pylori infection is a cause of peptic ulcer disease, gastric mucosa-associated lymphoreticular tis- sue (MALT) lymphoma and gastric cancer [1]. Standard treatments for H. pylori that have been endorsed by US and European authorities rely on clarithromycin or met- ronidazole in conjunction with other antibiotics and acid inhibitors [2, 3]. The prevalence of clarithromycin and metronidazole resistance has increased significantly in recent years and there has been a corresponding decline in the eradication rate for H. pylori [4]. Eradication rates in most Western countries have declined to unacceptable values with approximately 1/5 patients failing eradication therapy [5]. A simple, short treatment regimen that would return eradication levels to the high values seen at the advent of H. pylori treatment is urgently needed [5]. Such a treatment regimen should have high efficacy against clarithromycin- and metronidazole-resistant strains of H. pylori as these strains are increasingly encountered in routine clinical practice. Triple therapy with a proton pump inhibitor (PPI), clarithromycin, and either amoxicillin or metronidazole is the most popular treatment regimen to cure H. pylori infection among primary care physicians and gastroen- terologists in the USA and Europe [6–8] . However, two double-blind, US multicenter studies recently found dis- appointingly low eradication rates with this regimen. In one study, 75.6% of 402 patients and in the other, 77.2% Key Words Helicobacter pylori infection  Chronic gastritis  Eradication therapy  Peptic ulcer disease Abstract Helicobacter pylori is a widespread disease causing most of the peptic ulcer diseases and low-grade mucosa-associated lymphoreticular tissue (MALT) lymphoma. Moreover, H. py- lori is a proven environmental risk factor for gastric carcino- ma and it has been recognized as a type 1 carcinogen factor. A combination of drugs has been proposed, using a proton pump inhibitor (PPI), amoxicillin, clarithromycin, metronida- zole and tetracycline to treat the infection. Since 1996, ac- cording to the European guidelines, the first-line approach using PPI, amoxicillin and clarithromycin or metronidazole has been suggested. Seven days of quadruple therapy with PPI (or ranitidine), tetracycline, bismuth salts and metronida- zole has been reserved as second-line treatment. To improve the eradication rate of the triple therapy, a different combi- nation of the available antibiotics has been proposed, con- sisting of a 10-day sequential regimen. A second-line levo- floxacin-amoxicillin-based triple therapy given for 10 days has been proposed, obtaining a high eradication rate, sug- gesting this regimen to be a suitable retreatment option in eradication failure. A third-line treatment with rifabutin- based regimen has been proposed. Copyright © 2007 S. Karger AG, Basel Prof. Dino Vaira Department of Internal Medicine and Gastroenterology, S. Orsola Hospital Via Massarenti 9, IT–40138 Bologna (Italy) Tel. +39 051 636 4140 E-Mail vairadin@med.unibo.it © 2007 S. Karger AG, Basel 0257–2753/07/0253–0203$23.50/0 Accessible online at: www.karger.com/ddi