Do you empirically treat for Helicobacter pylori (H. pylori) after surgery for a perforated duodenal ulcer?

From the Guidelines

No, empirical treatment for H. pylori is not recommended after surgery for a perforated duodenal ulcer without confirming the presence of H. pylori infection. The most recent and highest quality study, 1, suggests that confirming the result of H. pylori test and initiating eradication therapy in H. pylori-positive patients prior to discharge would appear to be a more appropriate strategy than to apply empirical therapy to all patients with bleeding peptic ulcer.

Recommended Approach

• All patients having a perforated duodenal ulcer should undergo H. pylori testing, as recommended by 1 and 1.
• The urea breath test (UBT) and stool antigen testing are acceptable non-invasive tests with high sensitivity and specificity, as stated in 1.
• If H. pylori infection is confirmed, eradication therapy should be initiated, as recommended by 1 and 1.
• The standard approach involves triple therapy consisting of a proton pump inhibitor, amoxicillin, and clarithromycin for 14 days, as suggested by 1.

Eradication Therapy

• Standard triple therapy (amoxicillin, clarithromycin, and PPI) regimen is recommended as first-line therapy if low clarithromycin resistance is present, as stated in 1.
• Alternative regimens include sequential therapy with four drugs (amoxicillin, clarithromycin, metronidazole, and PPI) or a 10-day levofloxacin-amoxicillin triple therapy, as recommended by 1.
• The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community, as suggested by 1.

Follow-up

• After completing the antibiotic course, patients should continue a proton pump inhibitor for 4-8 weeks to ensure complete ulcer healing, as recommended by the example answer.
• Confirmation of H. pylori eradication with a urea breath test or stool antigen test should be performed at least 4 weeks after completing antibiotic therapy and while off proton pump inhibitors for at least 2 weeks, as recommended by the example answer.

From the FDA Drug Label

The combination of omeprazole plus clarithromycin plus amoxicillin was effective in eradicating H. pylori. H. pylori eradication was defined as no positive test (culture or histology) at 4 weeks following the end of treatment, and two negative tests were required to be considered eradicated of H. pylori. Eradication of H. pylori has been shown to reduce the risk of duodenal ulcer recurrence.

Empirical Treatment for H. pylori after Surgery for Perforated Duodenal Ulcer:

• The FDA drug label supports the use of a combination regimen including omeprazole, clarithromycin, and amoxicillin for the eradication of H. pylori in patients with duodenal ulcer disease 2.
• The label also states that eradication of H. pylori has been shown to reduce the risk of duodenal ulcer recurrence 3.
• Therefore, it is reasonable to empirically treat for H. pylori after surgery for a perforated duodenal ulcer, using a combination regimen such as omeprazole, clarithromycin, and amoxicillin.
• Key Considerations:
  • H. pylori eradication is defined as two negative tests at 4 weeks following the end of treatment.
  • The combination regimen should be used for 14 days.
  • Eradication of H. pylori reduces the risk of duodenal ulcer recurrence.

From the Research

Empirical Treatment for Helicobacter pylori after Surgery for Perforated Duodenal Ulcer

• The treatment of Helicobacter pylori (H. pylori) infection is crucial in patients with gastric or duodenal ulcer, as it improves healing and prevents complications and recurrences 4.
• A study published in 1998 proposed an alternative therapeutic plan for the treatment of perforated duodenal ulcer, which includes the evaluation and treatment of H. pylori infection 5.
• The choice of antibiotics for H. pylori eradication is based on trials with a primary endpoint of a negative urea breath test, and the first-choice empirical treatment consists of three antibiotics: amoxicillin, clarithromycin, and metronidazole, plus a proton-pump inhibitor (PPI) 4.
• The treatment regimen for H. pylori eradication may vary, and factors such as resistance to clarithromycin and metronidazole, as well as the patient's CYP2C19 genotype status, can influence the success of treatment 6, 7.
• A systematic review of proton-pump inhibitors in H. pylori eradication found that the most important risk factor for eradication failure is resistance to clarithromycin and metronidazole 6.
• Studies have shown that high doses of omeprazole and amoxicillin can cure H. pylori infection in patients who have failed previous treatments, including those with clarithromycin-resistant strains 8, 7.
• The eradication rates of H. pylori can be influenced by factors such as patient age, smoking status, and hyperacidity, with older patients and non-smokers having higher eradication rates 8.