Multi-resistant H. pylori

[fbagovic]

Dear Prof. Marshall,
My name is Davorin and I live in Croatia.
I have corpus predominant chronic mild atrophic gastritis with H.pylori infection. I already had 3 eradication schemes, but unfortunately I'm still H.p. positive. New antibiogram shows resistance to: Clarithromycin (MIC=64 mcg/ml), Metronidazol (MIC=64 mcg/ml), Levofloxacin (MIC=2 mcg/ml); following antibiotics are at the breakpoint: Rifabutin (MIC=1 mcg/ml), Moxifloxacin (MIC=1 mcg/ml).
As I underwent successful neurosurgery, furazolidone is contraindicated.
Do you see some way out ?

Now I found out that I'm in deep trouble, so I'm trying to educate myself.
Hopefully after your advice I'll look like this

Thank you in advance

[barjammar]

Wow - you gave me all the information I needed. Firstly, note that very high doses of PPI (rabeprazole 20 mg tid) plus amoxycillin (1G tid) will have a cure rate of 60-70%. The antibiogram to penicillin is not very important - Hp is almost always suceptible. Since you are very limited in your coices, perhaps do the above treatment with bismuth (De-Nol) double dose (120 mg, 2 tabs QID) for two weeks. You could add something else in the last 7 days of that treatment; tetracycline (250 mg, 2 tabs qid) or maybe furazolidone (100 mg tid) would be better if it was compatible with your condition. Discuss drug interactions with your actual doctor and do some more research - update us about what you find as it will help others.
It is likely that you will get some side effects with this rather strong combination.

[fbagovic]

Thank you for supporting me.
I was also thinking how to add some other antibiotic to amoxicillin to increase the eradication chances, and as you suggested tetracycline is one of the possibilities. Unfortunately I found out that tetracycline may reduce the effect of penicillin. Is this the reason you are suggesting to add tetracycline in the last 7 days (and not during the whole therapy)?
My overall condition is good (44 y), but due to neurosurgery (neurinoma acusticus) I'd like to avoid Furazolidone and keep the oncological risk at minimum. What do you think would adding Alinia (Nitazoxanide) in the last 7 days of treatment be of help?
Beside probiotics, any furher idea how to decrease the bacterial overload and break the biofilm (some kind of pre-treatment)?
I'll update the community on the result, let's stay in touch until then.

[barjammar]

I doubt that the tetracycline and amoxicillin interaction is relevant in the stomach. However, tetracycline and bismuth probably chelate to each other and to the mucus layer and thus last longer in the stomach so they might be synergistic - at least they have been used in lots of triple therapies. Nitazoxanide is a reasonable extra drug to use - as long as there is plenty of PPI also. It is pretty safe in my experience. So start off with the bismuth, amoxi and PPI, then add the tetracycline and nitazoxanide after 5 days and continue all for 10 days total. About 30 minutes after taking it, lie down and roll 360 degrees twice to better coat the stomach. (maybe say a prayer!!). Let me know if it works.