We read about your series of patients with multi-resistant strains with great interest. We think this series emphasise the importance of different therapeutic and diagnostic approaches now needed across Europe. May we assume that the patient series is from Italy? In northern European countries, this degree of resistance would be unusual. However, it is becoming increasingly common in southern European countries, and the recent Maastricht guidance no longer recommends a proton pump inhibitor (PPI) with clarithromycin and metronidazole as first-line treatment.
We were very surprised by the very high resistance rates to amoxicillin and tetracycline, as this is highly unusual and therefore it would be interesting to have further work done on these isolates. The authors do not say how long they waited between eradication treatment and endoscopy for culture and susceptibility testing, and if PPIs were stopped. Their letter suggests that patients were still on PPIs; despite taking specimens from the body, ongoing PPIs treatment could still lead to culture failure. In these difficult cases, it may be better to delay endoscopy for longer than the 1 month recommended by Maastricht IV, and, in addition, ensure that PPIs are stopped for at least 2 weeks.