Zala G, Schwery S, Giezendanner S, Flury R, Wüst J, Meyenberger C, Wirth H P
Departement für Innere Medizin, der Universität, Zürich.
Schweiz Med Wochenschr. 1996 Feb 3;126(5):153-8.
Helicobacter pylori (H. pylori) eradication rates with omeperazole/amoxicillin range from 0-90%. The best regimen for retreatment after failure of omeprazole/amoxicillin has not been established so far. The aim of this prospective study was to evaluate the efficacy of triple therapy with bismuth, tetracycline and ornidazole in eradicating H. pylori after failure of omeprazole/amoxicillin. 79 duodenal ulcer patients with H. pylori infection were treated with oral omeprazole (40 mg bid) and amoxicillin solute (750 mg tid) for 10 days. Eradication rate was 28/79 (35%) and was distinctly lower in smokers (> 10 cigarettes/day) vs nonsmokers (10/49 [20%] vs 18/30 [60%], p < 0.001). 37 patients with persistent H. pylori infection in whom omeprazole/amoxicillin had failed agreed to retreatment with triple therapy. Persistence of H. pylori was confirmed by histology (3 antral and 2 gastric body biopsies; H&E, Giemsa), urease test (CLO) and/or H. pylori culture. Patients smoking > 10 cigarettes/day were classified as smokers. Retreatment consisted of oral bismuth-subcitrate 4 x 120 mg/d for 28 days (day 1-28), tetracycline 4 x 500 mg/d and ornidazole 3 x 500 mg/d for 10 days (day 1-10). Control endoscopy was done 30 days after the end of treatment. Criteria for H. pylori eradication was negative urease test, culture and histology. 34/37 patients (6 females/28 males; 39 [23-64] years) completed the study (24/34 smokers, 10/34 nonsmokers). 3/37 patients dropped out because of side effects (n = 1) or incompliance (n = 2). H. pylori subcultures for resistance testing were possible in 32/34 patients: H. pylori was metronidazole-sensitive in 11/32 (1 female, 10 males; 38 [24-55] years; 9 smokers, 2 nonsmokers) and metronidazole-resistant (minimal inhibitory concentration for metronidazole > 8 mg/ml) in 21/32 (5 females, 16 males; 40 [23-64] years; 13 smokers, 8 nonsmokers). The overall H. pylori eradication rate of the triple therapy was 27/34 (79%). H. pylori was eradicated in 19/24 (79%) smokers and in 8/10 (80%) nonsmokers. Eradication rate for metronidazole-sensitive H. pylori was 11/11 (100%) vs 14/21 (67%) for metronidazole-resistant H. pylori (p = 0.012). Triple therapy is effective and safe in eradicating H. pylori in patients after failure of omeprazole/amoxicillin. Smoking had no negative effect on the eradication rate of the triple therapy after failure of omeprazole/amoxicillin. Eradication failures were due to metronidazole-resistance.
奥美拉唑/阿莫西林治疗幽门螺杆菌（H. pylori）的根除率在0%至90%之间。迄今为止，奥美拉唑/阿莫西林治疗失败后最佳的再治疗方案尚未确定。这项前瞻性研究的目的是评估铋剂、四环素和奥硝唑三联疗法在奥美拉唑/阿莫西林治疗失败后根除幽门螺杆菌的疗效。79例幽门螺杆菌感染的十二指肠溃疡患者接受口服奥美拉唑（40毫克，每日两次）和阿莫西林分散片（750毫克，每日三次）治疗10天。根除率为28/79（35%），吸烟者（每天>10支香烟）的根除率明显低于不吸烟者（10/49 [20%] 对18/30 [60%]，p<0.001）。37例奥美拉唑/阿莫西林治疗失败后仍存在幽门螺杆菌感染的患者同意接受三联疗法再治疗。通过组织学检查（3块胃窦和2块胃体活检标本；苏木精-伊红染色、吉姆萨染色）、尿素酶试验（CLO）和/或幽门螺杆菌培养确认幽门螺杆菌持续存在。每天吸烟>10支香烟的患者被归类为吸烟者。再治疗方案为口服枸橼酸铋钾4×120毫克/天，共28天（第1 - 28天），四环素4×500毫克/天和奥硝唑3×500毫克/天，共10天（第1 - 10天）。治疗结束后30天进行对照内镜检查。幽门螺杆菌根除的标准是尿素酶试验、培养和组织学检查均为阴性。34/37例患者（6例女性/28例男性；年龄39 [23 - 64]岁）完成了研究（24/34例吸烟者，10/34例不吸烟者）。3/37例患者因副作用（n = 1）或不依从（n = 2）退出研究。32/34例患者的幽门螺杆菌进行了亚培养以检测耐药性：11/32例（1例女性，10例男性；年龄38 [24 - 55]岁；9例吸烟者，2例不吸烟者）的幽门螺杆菌对甲硝唑敏感，21/32例（5例女性，16例男性；年龄40 [23 - 64]岁；13例吸烟者，8例不吸烟者）的幽门螺杆菌对甲硝唑耐药（甲硝唑最低抑菌浓度>8毫克/毫升）。三联疗法的总体幽门螺杆菌根除率为27/34（79%）。19/24例（79%）吸烟者和8/10例（80%）不吸烟者的幽门螺杆菌被根除。对甲硝唑敏感的幽门螺杆菌根除率为11/11（100%），而对甲硝唑耐药的幽门螺杆菌根除率为14/21（67%）（p = 0.012）。三联疗法在奥美拉唑/阿莫西林治疗失败的患者中根除幽门螺杆菌有效且安全。吸烟对奥美拉唑/阿莫西林治疗失败后的三联疗法根除率没有负面影响。根除失败是由于甲硝唑耐药。
