A 55-year-old man with H. pylori-positive duodenal ulcer is treated with standard triple therapy (omeprazole + amoxicillin + clarithromycin for 14 days). H. pylori eradication rates with this regimen have declined significantly in India due to:
- A Increased amoxicillin resistance
- B PPI underdosing reducing acid suppression
- C Clarithromycin resistance exceeding 15–20% ✓
- D Metronidazole cross-resistance
Explanation
Clarithromycin resistance is the primary driver of declining H. pylori eradication rates with standard triple therapy globally and in India, where resistance rates now exceed 15–20% in many regions. The Maastricht VI/Florence consensus (2022) recommends performing susceptibility testing or using bismuth quadruple therapy (omeprazole + bismuth + tetracycline + metronidazole) as first-line when clarithromycin resistance >15%. Amoxicillin resistance remains low (<1%). Concomitant or sequential therapy is an alternative. Metronidazole resistance is common but its inclusion in quadruple therapy partially overcomes resistance.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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