How to treat after Helicobacter pylori eradication failure?

Helicobacter pylori eradication failure generally concerns between 10 and 30% of the patients. When eradication failure occurs, it is necessary a) to try to identify the potential causes, b) to confirm the indication of eradicating H. pylori, and c) to choose a second line therapeutic strategy. Among the factors most frequently associated with failed eradication, are poor compliance, younger age, smoking, and weak gastric inflammatory activity. The major factor of resistance is related to the sensitivity of the bacterial strain to antibiotics used. In France, resistance to clarithromycin is around 10-15% and resistance to metronidazole around 30%. In order to limit development of resistance, it seems preferable to avoid associating clarithromycin and metronidazole in the first line treatment. At best, the first line treatment must follow the official recommendations (PPI-amoxicillin and clarithromycin). in the event of eradication failure, second line treatment calls upon tritherapy which, due to the low rate of resistance to amoxicillin, associates double-dose PPI, amoxicillin and the antibiotic not used during the first line treatment (metronidazole if clarithromycin was initially used and conversely). This approach allows to eradicate between 50 and 80% of the first-line failure patients. In case of further failure a culture with measurement of the strain sensitivity is required. Subsequent treatment associates PPI with. the antibiotics to which the strain is sensitive for a longer duration. In some cases, other effective antibiotics, such as rifabutin, might be used in these circumstances.