Gastric and duodenal ulcers cause unpleasant symptoms and sometimes lead to severe complications such as bleeding or perforations. Most gastric or duodenal ulcers are associated with a Helicobacter pylori infection.

In cases of gastric or duodenal ulcers proven to be associated with a Helicobacter pylori infection, treating the infection improves the healing rate of the ulcer and reduces the frequency of complications, especially bleeding, and recurrences.

In 2015, the efficacy of the combination used since the late 1990s, a proton-pump inhibitor (omeprazole to reduce stomach acid) + clarithromycin + amoxicillin (two antibiotics) for 7 days, is often reduced as a result of Helicobacter pylori’s increasing resistance to clarithromycin.

The choice of first-line antibiotic treatments has been thoroughly evaluated through randomised trials. In practice, in 2015, in adults suffering from a gastric or duodenal ulcer with as-yet-untreated Helicobacter pylori infection, the evaluation data indicate a probabilistic antibiotic treatment with a combination of amoxicillin + clarithromycin + metronidazole, administered together or successively over 5-day periods, plus a proton-pump inhibitor (omeprazole).

If the initial treatment is unsuccessful, there is no tried-and-tested empirical strategy. One option is to replace clarithromycin with a fluoroquinolone or a tetracycline.

©Prescrire 1 January 2016

"Helicobacter pylori and gastric or duodenal ulcer. First-line empirical treatment in 2015: amoxicillin + clarithromycin + metronidazole" Prescrire Int 2016; 25 (167): 18-23. (Pdf, subscribers only).