[Helicobacter pylori infection: what to do after first intent treatment failure?]

First intent therapy of H. pylori infection is triple therapy combining PPI, amoxicillin and clarithromycin for 7 to 10 days. Due to the increasing rate of primary resistance to clarithromycin, expected eradication rates are below 70%. Consequently, treatment effect has to be systematically assessed by urea breath test: in case of failure, a second line triple therapy combining PPI, amoxicillin and metronidazole instead of clarithromycin for 14 days should be prescribed. Using this strategy, the global eradication rate after two lines of treatment is 90%. Rescue triple therapies combine PPI and amoxicillin with either levoloxacin or rifabutin for 10 days. Levofloxacin should be used first in order to prevent development of rifabutin resistance among mycobacteria. The increasing rate of quinolone resistance led to the proposal to perform culture with susceptibility testing prior to third line therapy.