Candidates for Antibiotic Treatment. Antibiotic regimens that eradicate H. pylori are now known to cure ulcers and reduce the risk for both peptic and duodenal ulcer bleeding. One computer analysis even suggests that eliminating H. pylori infection could significantly increase the lifespan of certain individuals with peptic ulcers, such as younger adults.

Antibiotics are clearly indicated for patients with strong evidence, particularly from endoscopy, for both ulcers and H. pylori. Some experts even recommend antibiotics for patients who have dyspepsia and evidence of H. pylori from blood or breath tests even if the presence of ulcers has not been confirmed. Many believe that persistent dyspepsia is such a strong risk factor for ulcers that eliminating the bacteria in infected people may not only prevent them in many people but also lower the risk for stomach cancer. 

Drug Regimens. At least five effective drug combinations are being used with success rates as high as 90% although cost varies widely. The best results are achieved using two antibiotics and a drug called a proton pump inhibitor, usually omeprazole (Prilosec), which suppresses acid production. A typical triple-drug regimen consists of omeprazole, clarithromycin (Biaxin), and amoxicillin. Other effective regimens substitute metronidazole (Flagyl) for clarithromycin or amoxicillin. ( H. pylori resistance to metronidazole is increasing, however.) Such three-drug regimens are well tolerated and effective, but very expensive. A less costly three-drug regimen using omeprazole, Bismuth (Pepto-Bismol), and tetracycline may be a good alternative, although it is less effective, side effects can be very distressing, and many patients cannot tolerate it. 

Side Effects and Noncompliance. Although antibiotic treatment is very effective against both gastric and duodenal ulcers, patient compliance is poor. The triple-drug regimens are complicated and require many pills a day. Side effects from one or more of these drugs occur in up to 30% of patients. Cases of severe diarrhea have occurred during treatment. One study indicates that the long-term side effects of treatment include weight gain. Eliminating the bacteria also may increase risk for gastroesophageal reflux esophagitis (a cause of severe heartburn).

Follow-up and Success. Cure rates after antibiotic treatments range from 70% to 90%. Symptom relief after treatment does not always indicate success, nor, on the other hand, does persistence of dyspepsia necessarily mean that treatment has failed. Follow-up testing for the bacterial should be conducted no sooner than four weeks after therapy. (Test results before that time may not be accurate.) Studies are indicating that, at least in developed countries, once the bacteria is eliminated, ulcers recur at an annual rate of less than 10%. (Reinfection with the bacteria may be possible, particularly in areas where the incidence of H. pylori is very high and sanitary conditions are poor.) 

Other Treatments for Ulcers Caused by H. Pylori

Elderly patients with ulcers caused by H. pylori but who cannot tolerate the side effects of the antibiotic therapy may continue to benefit from H2 blockers, the older treatment for peptic ulcers. Some experts recommend H2 blockers for people who test positive for H. pylori but have symptoms only of dyspepsia and no sign of peptic ulcers. Their argument is based on reducing costs; young people who meet this criteria but who have other risk factors for ulcers should discuss options with their physician. Some researchers are also concerned that eradicating H. Pylori may not be effective against bleeding episodes from existing ulcers and that H2 blockers will remain important for treating this condition. By decreasing acid production, the body has the opportunity to heal itself. H2 blockers temporarily heal up to 95% of ulcers after eight weeks, but they do not prevent recurrence of ulcers. One study, for example, showed that long-term therapy with the H2 blocker ranitidine (Zantac) significantly prevented recurring bleeding in people who had experienced severe hemorrhaging from non-NSAID-induced ulcers.