How to treat Helicobacter pylori infection--should treatment strategies be based on testing bacterial susceptibility? A personal viewpoint.

Peptic ulcer disease is an infectious disease. Only antibiotic regimens that achieve a 90% cure should be used to treat this infection. Antimicrobial susceptibility is the main determinant in the success of therapy; cure rates are usually lower in resistant strains. As in any other infectious disease it is essential in treatment studies to stratify results according to pretreatment bacterial susceptibility. Cure-rates have to be reported separately for sensitive and resistant strains. It must be realized that a study achieving a high cure rate with a certain regimen can either have included few patients with resistant strains or, alternatively, the regimen tested can have a high efficacy in resistant strains. This issue is fundamental and only if that information is available, do we know whether or not we can reproduce the results reported in that particular study in a different population. We have reviewed all Helicobacter studies that tested pretreatment bacterial susceptibility. The results achieved with dual therapy, bismuth triple therapy, proton pump inhibitor triple therapy and quadruple therapy in sensitive and resistant strains are discussed. Based on these data, treatment recommendations are made for empirical treatment in areas with low resistance rates and those with high resistance rates. If treatment is individualized and based on the antibiogram then easier, shorter and cheaper regimens seem possible.