Peptic ulcer disease: defining the treatment strategies in the era of Helicobacter pylori.
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Peptic ulcer disease continues to be a major health care problem costing the public billions of dollars each year. Recent evidence confirms a major role for Helicobacter pylori infection in the natural history of most cases of peptic ulcer disease. The most established and effective antibiotic treatment for the eradication of H. pylori has been the classic bismuth "triple therapy" regimen containing bismuth, metronidazole, and tetracycline. However, pretreatment resistance to metronidazole, poor compliance, and side effects have limited the widespread acceptance of bismuth triple therapy for routine use. Recent studies suggest that the combination of one or two antibiotic agents and a proton pump inhibitor offers a better tolerated regimen than bismuth triple therapy. Efficacy is similar with respect to eradication of H. pylori, and the combined use of a proton pump inhibitor assures rapid symptom relief and ulcer healing. Although the mechanisms by which H. pylori eradication is effected, the optimal dosing schedules, and the specific antimicrobial agents to be administered require further study, the combination of a proton pump inhibitor and one or two antibiotics promises to be an appropriate first-line treatment for peptic ulcer disease.