Traitement séquentiel de l’infection à Helicobacter pylori chez l’enfant

Standard triple and sequential therapies for Helicobacter pylori eradication: an update

H. pylori infection remains a worldwide spread disease with a definite morbidity and mortality. Unfortunately, no current therapy regimen is able to cure the infection in all treated patients. The efficacy of the widely recommended triple therapies is decreasing, and a novel 10-day sequential therapy has been proposed. Data of 3 previous meta-analyses showed a significantly higher eradication rate following the sequential as compared to the 7-10 days triple therapies. The sequential therapy achieved significantly better results than triple therapies in children, elderly patients, non-ulcer dyspepsia patients, and in those infected with resistant strains towards either clarithromycin or metronidazole. We identified further 10 randomized trials. By pooling data, H. pylori infection was cured in 2,454 (86%; 95% CI: 84.7-87.3) out of 2,853 patients with the sequential therapy and in 2,320 (75.3%; 95% CI: 73.8-76.9) out of 3,079 patients treated with standard triple therapies (p<0.001), corresponding to a number to treat (NNT) of 9. The comparison between the 10-day sequential regimen and 14-day triple therapies deserves further investigations.

Low efficacy of clarithromycin including sequential regimens for Helicobacter pylori infection

BACKGROUND

Sequential treatment for Helicobacter pylori (H. pylori) appears to achieve a better eradication rate than triple therapy. However, most of the data have been reported from the Italy, and studies from different population are needed before it is recommended in clinical practice. The present study aimed to assess and compare the efficacy of two separate clarithromycin including sequential regimens in Turkey which is well known with high clarithromycin and metronidazole resistance to H. pylori.

METHODS

Consecutive H. pylori -positive patients with non-ulcer dyspepsia were randomly allocated to one of the two sequential regimens; the first group was given lansoprazole 30 mg b.i.d. plus amoxicillin 1 g b.i.d. for the first week, followed by lansoprazole 30 mg b.i.d., clarithromycin 500 mg b.i.d., and metronidazole 500 mg t.i.d. for the second week (LA-CM). The second arm was given the same regimen but tetracycline500 g q.i.d. instead of metronidazole (LA-CT). H. pylori was detected with urea breath test (UBT) and histology before enrollment. UBT was repeated at 6th weeks after treatment.

RESULTS

A total of 200 patients were enrolled in groups and 179 of them completed their protocols. The cumulative per protocol ("PP") and intention-to-treat ("ITT") eradication rates were 74.3% and 66.5% in all patients, respectively. Both "PP" (78.2% vs 70.1%) and "ITT" (72% vs 61%) eradication rates were better in LA-CT group than LA-CM group, but the differences were not statistically significant (p > .05). Both regimens were well tolerated, and the incidence of adverse effects was comparable.

CONCLUSION

Two weeks clarithromycin including sequential regimens with metronidazole or tetracycline were not achieved acceptable eradication rates in Turkey.

Sequential therapy versus tailored triple therapies for Helicobacter pylori infection in children

AIMS

The aim of the study was to compare sequential versus tailored triple therapy regimens on Helicobacter pylori (H pylori) eradication rates in children and to assess the effect of antimicrobial susceptibility.

PATIENTS AND METHODS

Prospective, open-label, multicenter study. Children received randomly either a 10-day sequential treatment comprising omeprazole (OME) with amoxicillin for 5 days and OME, clarithromycin (CLA), and metronidazole (MET) for the remaining 5 days, or a 7-day triple therapy comprising OME with amoxicillin and CLA in cases of a CLA-susceptible strain or MET in cases of CLA-resistant strain. H pylori eradication was assessed by C-urea breath test.

RESULTS

One hundred sixty-five children, 95 girls and 70 boys, of median age 10.4 years, were included. The intention-to-treat (ITT) eradication rate was 76.9% (sequential 68/83 = 81.9%, triple therapy 59/82 = 71.9%, ns), and the per-protocol (PP) eradication rate was 84.6% (sequential 68/77 = 88.3%, triple therapy 59/73 = 81.8%, ns). Eradication rates tended to be higher using the sequential treatment, but the difference was only statistically significant for ITT analysis in children harboring both CLA- and MET-susceptible strains (87.8% vs 68.5%, odds ratio [OR] 3.3, P = 0.03). Both ITT and PP eradication rates were significantly lower with sequential treatment in CLA-resistant compared with CLA-susceptible strains (ITT: 56.2% vs 72.7%, OR 5.5, P = 0.008; PP 64.3% vs 80.0%, OR 7.9, P = 0.009). Both treatments were well tolerated.

CONCLUSIONS

Sequential treatment is greatly effective for eradicating H pylori in children except in CLA-resistant strains. Sequential treatment can be used as a first-line therapy, but only in areas with a low CLA resistance rate.

The prevalence and incidence of Helicobacter pylori-associated peptic ulcer disease and upper gastrointestinal bleeding throughout the world

Due to heightened awareness regarding testing for and eradication of infection, the prevalence and incidence of H pylori infection (and by extension the prevalence and incidence of peptic ulcer disease) appear to have declined in recent years. However, antimicrobial resistance is mounting and traditional clarithromycin- or metronidazole-containing triple therapies may no longer be highly effective at eradicating the infection. Combined bismuth- and metronidazole-containing quadruple therapy or sequential 4-drug therapy may be better choices for first-line treatment against this unique pathogen that is ideally suited to survive in the human stomach.

Sequential therapy for Helicobacter pylori eradication: a critical review

BACKGROUND

Alternative treatment regimens for standard triple therapy are urgently needed.

AIM

To critically review the evidence on the role of "sequential" regimen for the treatment of Helicobacter pylori infection.

METHODS

Bibliographical searches were performed in MEDLINE and international congresses.

RESULTS

Several pooled-data analyses and meta-analyses have demonstrated that sequential regimen is more effective than standard triple therapy. Sequential therapy is not affected by bacterial (CagA status, infection density) and host factors (underlying disease, smoking). Clarithromycin resistance seems to be the only factor reducing their efficacy. However, even in these patients, an acceptable >75% eradication rate can be achieved. Unfortunately, almost all the studies have been performed in Italy. Whether it is necessary to provide the drugs sequentially or if the 4 components of sequential therapy can be given concurrently is unclear. Nonbismuth quadruple therapy seems to be an effective and safe alternative to triple therapy and is less complex than sequential therapy.

CONCLUSIONS

Sequential therapy is a novel promising treatment approach that deserves consideration as a treatment strategy for H. pylori infection. However, further robust assessment across a much broader range of patients is required before sequential therapy could supplant existing treatment regimens and be generally recommended in clinical practice.

Sequential therapy vs. standard triple therapies for Helicobacter pylori infection: a meta-analysis

BACKGROUND

As standard triple therapies of achieve unsatisfactory eradication of Helicobacter pylori, several alternative regimens have been proposed.

OBJECTIVES

To systematically evaluate whether sequential treatment eradicates H. pylori infection better than standard triple therapies and compare the risk of adverse events with these two regimens.

METHODS

We searched electronic databases up to February 2008 for studies evaluating the efficacy of the 10-day sequential therapy vs. standard triple regimens for eradication of H. pylori. The pooled risk ratios (RR) and 95% confidence intervals (95% CI) were calculated.

RESULTS

We identified 11 randomized trials, including eight full-text manuscripts and three abstracts. Pooled analysis demonstrated clear superiority of the sequential therapy over 7-day triple regimen with an RR of 1.23 (95% CI 1.19-1.27), and over 10-day triple regimen with a RR of 1.16 (95% CI 1.10-1.23). Adverse event rates were similar. For sequential therapy vs. 7-day triple therapies, RR = 0.96, 95% CI 0.70-1.31.

CONCLUSIONS

Sequential therapy was associated with a higher eradication rate of H. pylori compared with both 7-day triple regimen and 10-day triple regimen.