Keep watch also on the faults of the patients which often make them lie about the
taking of things prescribed — Hippocrates, 4th century BC
Compliance with therapy is the single most important factor in Helicobacter
pylori (H. pylori)
eradication. Compliance with therapy has a
considerable influence on treatment failures in antibiotic-sensitive patients and in
the subsequent development of antibiotic resistance. This has major implications.
Eradication rates with standard proton pump inhibitor-amoxicillin-clarithromycin are
87.8% when strains are clarithromycin-sensitive and 18.3% when
clari-thromycin-resistant [Megraud, 2004
]. It has been proven that 10% of patients prescribed
eradication therapy will fail to take even 60% of
medications [Lee et al.
]. It has also been proven that progressively poorer levels of compliance
with therapy are associated with significantly lower levels of eradication. In one
study eradication levels of 96% were observed for patients who took 60% or more of
medications compared to 69% for those taking less than 60% of prescribed medications
[Graham et al. 1992
Compliance is a topic of much recent discussion in the medical literature. An
analysis revealed that the number of times the word itself has been cited in the
medical literature has grown at an exponential rate over the last 40 years [Düsing et al.
]. There has even been criticism of the term itself as it suggests a
didactic medical model which stresses obedience and is not patient centred, while
some opinions have suggested a newer model of ‘adherence’
which emphasises the patient as an autonomous partner in treatment [Lutfey and Wishner, 1999
The problems involved in ensuring compliance or adherence with medical therapy are
far from new, as the above quotation from Hippocrates illustrates.
Compliance with H. pylori eradication regimens is a multifactorial
process. Current evidence and published guidelines recommend complex and prolonged
eradication regimens, using a number of antibiotics and involving manipulation of
gastric pH as well. This complexity provides challenges for both the physician and
the patient. For the physician, it demands clear understanding of the pathogenesis,
sequelae and complications of H. pylori infection and a motivation
to test for and treat the infection where appropriate. The motivated physician can
then provide information to the patient which will lead to his or her empowerment to
play an active role in their treatment by complying with therapy. To do this demands
the knowledge outlined above on the physician's part. Trust, which is
implicit in the doctor–patient relationship, is also of paramount
importance here. The benefit gained from the eradication of H.
pylori such as reducing long-term risk of gastric cancer may not be obvious
to the patient. The patient's expectations of therapy need to be explored
as this benefit is often much more subtle than that gained from the prescription of
oral antibiotics for an uncomplicated respiratory or urinary tract infection. The
challenges for the patient wishing to comply with therapy may also be financial and
social, incorporating factors such as literacy. The combination of all of these
factors, however, is immaterial unless efficacious and evidence-based treatments are
available with adverse event profiles that are acceptable to both physician and
patient. As outlined in , these factors converge to influence compliance which leads to H.
Factors influencing compliance with therapy and subsequent eradication of