Eradication of H. pylori cures peptic ulcer disease. Bismuth and antibiotics in various combinations were tested at a single university hospital.
The standard treatment was bismuth subnitrate, metronidazole and oxytetracycline. A positive biopsy urease test was the main inclusion criterium, whereas a negative 14C-urea breath test performed at least four weeks after cessation of therapy was the main indicator of cured infection, and performed later for reinfection. In separate studies we tested the absorption of bismuth subnitrate compared to other bismuth preparations, what aspects of bismuth-based triple therapy are most important to obtain maximum eradication, what can be done to decrease side effects, and the reliability of diagnostic methods.
The absorption of bismuth from bismuth subnitrate was very low. More than 90% cure rates were usually obtained. Including metronidazole in the regimen increased side effects but was crucial for effectiveness. Spiramycine could replaced oxytetracycline without substantial loss of effectiveness. Effectiveness was decreased if the patients had recently used metronidazole. Aluminium containing antacids and chlorhexidine were not very useful. Side effects were frequent, up to 60%, but usually mild and very few patients withdrew from treatment. Adding ranitidine to the regimen reduced abdominal pain. 14C-urea breath test was the "gold standard" and the specificity of the biopsy urease test in diagnosing H. pylori infection was high.
Bismuth combination therapy combines high effectiveness with acceptable side effects and low cost. Biopsy urease test and urea breath test are reliable indicators of H. pylori infection.