中华医学会第八次全国消化疾病学术会议论文汇编 Hp分会场

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    ·分会场专题报告

    Recent advances of Helicobacter pylori research.

    Baylor College of Medicine, Houston, Texas, USA David Y. Graham, M.D

    As with other bacterial infections, successful treatment of Helicobacter pylori infections depends

    on the use of antibiotics to which the organism is susceptible. The goal of therapy is to

    consistently cure more than 95% of patients (eg, provide Grade A results). Like tuberculosis, H.

    pylori infection are difficult to cure and success generally requires several antimicrobials to be

    administered simultaneously. Duration of therapy is also important and depends upon whether

    resistance is present; 14 days is often best. With few exceptions, worldwide increasing macrolide

    resistance now undermines the effectiveness of the legacy triple therapy (eg, a proton pump

    inhibitor [PPI], clarithromycin and amoxicillin) and in most areas cure rates have declined to

    unacceptable levels (eg, Grade F or <81%). In most countries, the prevalence of antimicrobial

    resistance is now such that unless proven otherwise all patients should be considered as having

    resistant infections. Ideally therapy should be based on pretreatment susceptibility testing or

    knowledge of the local resistance patterns. The development of sequential therapy was one

    response to the problem of resistance. Sequential therapy has repeatedly been shown in

    head-to-head studies to be superior to legacy triple therapy. Sequential therapy, as originally

    described, was the sequential administration of a dual therapy (a PPI plus amoxicillin) followed by

    a PPI plus clarithromycin and tinidazole. It has been shown to be especially useful in

    clarithromycin resistance. Other methods to achieve acceptable eradication rates (eg, Grade A or B

    results) empirically include concomitant therapy, and bismuth containing quadruple therapy.

    Concomitant therapy is the name given to a 4 drug, 3 antibiotic, non-bismuth containing regime

    consisting of a PPI, amoxicillin, clarithromycin and a nitroimidazole. This has proven highly

    successful; there have been at least 9 publications with more than 700 patients reporting excellent

    success. Head-to-head comparison with sequential therapy showed it they were equivalent

    although concomitant therapy is less complicated than sequential therapy as all drugs are given

    and thus may be a better choice. Both can likely be improved to Grade A (>95% cure ITT) (ie,sequential therapy by continuing the amoxicillin through the second period, and both by

    increasing the doses and/or durations of therapy). Better appreciation of the role of acidity in

    treatment failure and need for long durations of therapy has resulted in a resurgence of interest in

    high dose PPI plus amoxicillin dual therapy either alone as a base for multidrug regimes.

    Antimicrobial choices following treatment failure is best approached by susceptibility testing. If

    not available, we recommended a quadruple therapy substituting at least one new drug for

    metronidazole/tinidazole and/or clarithromycin, if they have been used previously. An alternate

    would be to use a 14 day high dose PPI, amoxicillin-based triple therapy with rifabutin, a

    fluoroquinolone, or furazolidone. We propose that a change in focus from comparative studies

    designed to prove that a new therapy is superior to a known inferior therapy to demanding that

    efficacious therapies meet or exceed a pre-specified levels of success (ie, Grade A or B result).

    Ultimately, there is no justification for comparative testing which include an arm with known

    unacceptably low results. H. pylori gastritis is an infectious disease and should be approached

    and treated as such.

    Hp分会场 中华医学会第八次全国消化疾病学术会议论文汇编

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    H.pylori毒力因子及宿主基因多态性对H.pylori感染结局影响

    同济大学附属同济医院同济消化疾病研究所 郜恒骏

    生物芯片上海国家工程研究中心(201203)

    幽门螺杆菌(H.pylori)被发现25年了 ......