The 1996 European guidelines had the important merit of deciding, once and for all, a standardized treatment suggesting the use of a 1-week triple therapy as first choice in treating H. pylori infection.5 Nevertheless, a recent meta-analysis found a fairly low eradication rate (82% in 3655 patients) using a proton pump inhibitor, clarithromycin and amoxycillin combination.21 Moreover, our study and several other European studies have reported unsatisfactory results (eradication rate < 80%),4, 6–16 and similar results were also observed in a recent study performed in Japan.22 Furthermore, the eradication rate was even poorer with such treatment regimens in clinical practice (eradication rate of 67% in 469 patients).23 Therefore, more effective treatment regimens are required, so as to bring the H. pylori eradication rate closer to 100%. In one of our previous studies, we observed that the results of a treatment sequence comprising an initial 2-week dual therapy followed by a triple therapy in eradication failure patients were highly effective, while the inverse sequence gave disappointing results.20 These observations suggested that an initial treatment with amoxycillin could lead, in some way, to a higher efficacy of an eventual successive triple therapy. Therefore, in the present study, we have attempted to simplify this rather complex treatment and assessment sequence, by the use of consecutive uninterrupted short-term dual and triple therapy courses with no washout period. Using this therapy regimen, the H. pylori eradication rate obtained was very high. It is not known why an initial treatment using amoxycillin should result in a such high efficacy of the sequential treatment with a clarithromycin and tinidazole combination. Nevertheless, some hypotheses could be put forward: a reduced bacterial load after an initial amoxycillin course could facilitate H. pylori eradication during the immediately successive triple therapy course. Indeed, it has been found that a low bacterial load is associated with a high eradication rate after triple therapy regimen.24 Moreover, it has been found that amoxycillin treatment can convert H. pylori into a coccoid form, that is a viable but less virulent, and such a coccoid form may also be more susceptible to a later treatment using macrolides and imidazoles.25, 26 Consequently, further studies are warranted to verify these hypotheses. On the other hand, with the simultaneous administration of omeprazole, amoxycillin, clarithromycin and tinidazole (i.e. quadruple therapy) both more side-effects and a lower compliance rate would be expected.19, 22 Therefore, our strategy of using two consecutive treatments seems to lead both to higher efficacy and a lower rate of side-effects.
In the present study no response difference emerged between non-ulcer dyspepsia and peptic ulcer patients. This observation further strengthens the high efficacy of this treatment schedule, since it is known that H. pylori eradication following various therapy regimens can lead to a poorer response in non-ulcer dyspepsia patients than in those with peptic ulcer.11, 27, 28 This promising treatment schedule was well tolerated, safe and cheap. Indeed, further savings could be made by avoiding the urea breath test control in those patients without complicated ulcer disease when using this highly effective therapy regimen.
The successful eradication of H. pylori infection following a failed initial triple therapy is notoriously difficult to achieve, even using a 1-week quadruple therapy.17–21 In such patients, we previously obtained better results using a 2-week triple therapy based on ranitidine bismuth citrate.6 This therapy regimen was also successfully used in the present study in the eradication failure patient. Although we are only dealing with a single observation, it would seem that in the event of eradication failure with the proposed 10-day regimen, we can still achieve an effective second line of defence.
In conclusion, if our results are confirmed by other studies, the use of this effective and attractive ‘five plus five’ therapy schedule could find a place in clinical practice as an initial treatment for H. pylori infection.