Antonio Plaza

Re-treatment after Helicobacter pylori eradication failure.

AIM Currently, highly effective Helicobacter pylori eradication therapies are used, and although eradication failures still appear in a considerable proportion of cases, the therapeutic efficacy in such refractory cases has been only exceptionally studied. Therefore, our aim was to evaluate the appropriate attitude when eradication therapy fails. METHODS In 127 duodenal ulcer patients, several therapies with omeprazole (O) plus one or two antibiotics [amoxycillin (A), clarithromycin (C), metronidazole (M)] had failed to eradicate H. pylori. Re-treatment was administered depending on initial therapy; in no case was the same regimen repeated, and antibiotics with resistance risk (as C or M) were only re-administered using combination regimens with bismuth (B): O + A + C + B (when C was re-administered) and O + bismuth triple therapy (BTT) (when M was re-administered). RESULTS First therapy and eradication rates, with the corresponding second therapy, were: CONCLUSION BTT re-treatment in O + A failure achieves a relatively low eradication rate, probably lower than BTT for the first time, suggesting that other regimens should be tried. The following re-treatments are recommended in H. pylori eradication failure: in O + A failure, BTT (or O + BTT, as BTT re-treatment could be less effective than the initial BTT treatment); in O + C failure, O + A + M; in O + A + C failure, O + BTT; in O + A + M failure, O + A + C; and, finally, in O + C + M failure, O + BTT (or O + A + C + B).

Role of partner's infection in reinfection after Helicobacter pylori eradication.

Aim To evaluate whether the Helicobacter pylori status of the patients spouse plays a role in reinfection after eradication success, and to assess the possibility of transmission of H. pylori among partners by using molecular methods. Methods We studied prospectively 120 patients in whom H. pylori had been eradicated. Endoscopy with biopsies and a 13C-urea breath test were performed 1 month after completing therapy. The breath test was repeated in all patients at 6 and 12 months. At the 1-year follow-up visit (or before if reinfection occurred), a breath test was also performed on the patients partner. Samples for the molecular study included gastric biopsies from patients and gastric content obtained by the string test from partners. The heterogeneity of ureC was studied by enzymatic digestion with MseI and HhaI enzymes of a polymerase chain reaction (PCR) product of 1179 bp belonging to the ureC gene, and different band patterns were generated after electrophoresis. Results Four reinfections were diagnosed at 6 months, and four were diagnosed from 6 to 12 months (incidence 6.8% per patient-year). Seven of eight (87%) of the reinfected patients’ spouses were infected, but H. pylori infection of spouses was also frequent (76%) among non-reinfected patients. In the multivariate analysis, age of the patient (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.87 to 0.99, P < 0.05), δ13CO2 value after therapy (OR 2.51, 95% CI 1.14 to 5, P < 0.05), and therapy regimen (OR 6.23, 95% CI 1.25 to 31, P < 0.05) were the only variables that correlated with H. pylori recurrence. However, family variables (H. pylori status of spouse, breath test value of spouse, length of time couple had lived together, number of children living at home, household density) did not correlate with recurrences. Thus, the OR for the H. pylori status of spouse (adjusted by age, δ13CO2 and therapy) was 2.93 (95% CI 0.29 to 29, P > 0.05). H. pylori recurrence occurred in seven of 92 (7.6%) patients when the spouse was infected (95% CI 3.7% to 15%), and in one of 28 (3.6%) patients when the spouse was H. pylori-negative (95% CI 0.6% to 18%) (P > 0.05; however, the power of this comparison was < 20%). Therefore, even if the spouse was infected, 92.4% of patients will remain uninfected 1 year after H. pylori eradication. Three reinfected patients (at 1 year) and their partners (also infected) agreed to have the endoscopy and string test performed, respectively. The molecular study revealed that H. pylori strains involved were different in all cases. Conclusion Recurrence of H. pylori infection seems to be relatively infrequent, even if the patients spouse is H. pylori-positive. The molecular study demonstrated that the strains in reinfected patients and their partners are different, suggesting that the patients partner does not act as a reservoir for H. pylori reinfection.

Efecto de la erradicación de Helicobacter pylori sobre la recurrencia de la úlcera gástrica a lo largo de 12 meses

espanolFundamento. Valorar la influencia de la erradicacion de Helicobacter pylori sobre la incidencia de recurrencias ulcerosas durante un periodo de seguimiento de 12 meses en enfermos con ulcera gastrica. Pacientes y metodo. Se estudiaron prospectivamente a 73 enfermos con ulcera gastrica. Durante la endoscopia se tomaron, tanto de antro como de cuerpo, dos biopsias para estudio histologico (hematoxilina-eosina) y una para test rapido de la ureasa. Tambien se realizaron serologia y prueba del aliento con urea-13C. Cincuenta y seis pacientes infectados por H. pylori fueron seguidos tras administrar una terapia erradicadora con omeprazol, claritromicina y amoxicilina. Inmediatamente despues de completar el tratamiento erradicador, se llevo a cabo una endoscopia de control de la cicatrizacion. Al mes de finalizar la terapia se realizo una segunda endoscopia con estudio histologico y un test del aliento (se definio la erradicacion como la ausencia de H. pylori por ambas tecnicas). Finalmente, para estudiar las recurrencias ulcerosas se efectuo de nuevo una endoscopia a los 6 y 12 meses. Resultados. La edad media de los pacientes estudiados fue de 54 ± 13 anos, y el 69% eran va-rones. La tasa acumulada de recurrencias ulcerosas a los 12 meses en los grupos con exito y fracaso erradicador fue, respectivamente, del 2,3% (IC del 95%, 0-12%) y del 70% (IC del 95%, 34-93%) (?2: 23,9; p Conclusiones. La erradicacion de H. pylori se asocia con una drastica reduccion de la recidiva de la ulcera gastrica, con una tasa de recurrencia acumulada durante 12 meses de solo el 2,3%. Esto indica que podria lograrse la curacion definitiva de esta enfermedad mediante la erradicacion del microorganismo. EnglishBackground: To study the influence of Helicobacter pylori eradication on the incidence of ulcer recurrence during 12 months of follow-up in gastric ulcer patients. Patients and methods: Seventy-three patients with gastric ulcer were prospectively studied. At endoscopy two biopsies from both antrum and body for haematoxylin-eosin staining and one for rapid urease test were obtained. Likewise, serology and 13C-urea breath test were carried out. Fifty-six H. pylori infected patients were monitored after giving an eradication therapy with omeprazole, clarithromycin and amoxicillin. A first control endoscopy was performed immediately after completing treatment to confirm ulcer healing. A second control endoscopy (with histologic study) and a breath test were performed one month after completing therapy (eradication was defined as the absence of H. pylori by both methods). Finally, an endoscopy was repeated at 6 and 12 months to study ulcer recurrences. Results: Mean age was 54 ± 13 years (69% males). Cumulative ulcer recurrence rate for 12 months, respectively for patients with eradication success and failure, was 2.3% (95% CI, 012%) and 70% (34-93%) (?2: 23.9; p Conclusions: H. pylori eradication is associated with a dramatic reduction on the recurrence of gastric ulcer, with a cumulative recurrence rate during 12 months of only 2.3%, which suggests that definitive cure of gastric ulcer disease is possible by means of microorganism eradication.