Ellenrieder V, Boeck W, Richter C, Marre R, Adler G, Glasbrenner B
Dept. of Internal Medicine, University of Ulm, Germany.
Scand J Gastroenterol. 1999 Aug;34(8):750-6. doi: 10.1080/003655299750025660.
Triple therapy with a proton-pump inhibitor (PPI) in combination with metronidazole and clarithromycin is the method of choice for eradication of Helicobacter pylori. Failures have been primarily blamed on the development of resistance to clarithromycin. The present study investigated the prevalence and clinical significance of resistance to clarithromycin and metronidazole in determining therapeutic success of both triple therapy as a primary eradication method and high-dose dual therapy in non-responders.
On the basis of prior therapy, H. pylori-positive patients were assigned to one of two groups in the present prospective study. Group A (n = 93) included patients who had not undergone any prior eradication treatment, whereas group B (n = 15) consisted of patients who had received clarithromycin but in whom eradication had been unsuccessful. All patients underwent endoscopy with biopsy for bacterial culture and resistance studies. Patients in group A were treated with a 7-day regimen of pantoprazole (40 mg twice daily), metronidazole (500 mg twice daily), and clarithromycin (250 mg twice daily), whereas those in group B received omeprazole (40 mg three times a day) and amoxycillin (1000 mg three times a day ) for 14 days. Success of the eradication treatment was ascertained by means of the 13C urea breath test.
In group A resistance to clarithromycin and metronidazole was identified in 3 patients (4.9%) and in 14 patients (22.9%), respectively. Eradication proved successful in 78 of 84 patients (92.6%) followed up. Two of the 3 patients with primary clarithromycin resistance and 1 of the 14 patients with metronidazole resistance did not respond to treatment. In group B isolated or combined resistance to clarithromycin was found in seven patients, whereas another four showed isolated resistance to metronidazole. Eradication proved successful in 10 of 13 controlled patients (76.9%) followed up, and only 2 patients reported severe side effects.
Determination of antibiotic resistance before initiating therapy is not necessary, since primary resistance to clarithromycin is rare. The Italian triple therapy remains a highly effective primary therapeutic method. Further, routine determination of resistance in non-responders also seems to be superfluous because high-dose dual therapy is an effective and well-tolerated second-line therapy regardless of the patients' resistance status.
质子泵抑制剂（PPI）联合甲硝唑和克拉霉素的三联疗法是根除幽门螺杆菌的首选方法。治疗失败主要归咎于对克拉霉素产生耐药性。本研究调查了克拉霉素和甲硝唑耐药性的发生率及其在确定三联疗法作为一线根除方法和对无反应者采用高剂量双联疗法治疗成功与否方面的临床意义。
在本前瞻性研究中，根据既往治疗情况，将幽门螺杆菌阳性患者分为两组。A组（n = 93）包括未接受过任何根除治疗的患者，而B组（n = 15）由接受过克拉霉素治疗但根除未成功的患者组成。所有患者均接受内镜检查并取活检进行细菌培养和耐药性研究。A组患者接受为期7天的泮托拉唑（40 mg，每日两次）、甲硝唑（500 mg，每日两次）和克拉霉素（250 mg，每日两次）治疗方案，而B组患者接受奥美拉唑（40 mg，每日三次）和阿莫西林（1000 mg，每日三次）治疗14天。通过¹³C尿素呼气试验确定根除治疗是否成功。
A组中，分别有3例患者（4.9%）对克拉霉素耐药，14例患者（22.9%）对甲硝唑耐药。在随访的84例患者中，78例（92.6%）根除治疗成功。3例原发性克拉霉素耐药患者中有2例、14例甲硝唑耐药患者中有1例治疗无反应。B组中，7例患者存在对克拉霉素的单独或联合耐药，另外4例显示对甲硝唑的单独耐药。在随访的13例对照患者中，10例（76.9%）根除治疗成功，只有2例患者报告有严重副作用。
由于原发性克拉霉素耐药罕见，开始治疗前不必进行抗生素耐药性检测。意大利三联疗法仍然是一种高效的一线治疗方法。此外，对无反应者常规进行耐药性检测似乎也没有必要，因为无论患者的耐药状态如何，高剂量双联疗法都是一种有效且耐受性良好的二线治疗方法。
