Levofloxacin versus clarithromycin in a 10 day triple therapy regimen for first-line Helicobacter pylori eradication: a single-blind randomized clinical trial

Bovine lactoferrin enhances the efficacy of levofloxacin-based triple therapy as first-line treatment of Helicobacter pylori infection: an in vitro and in vivo study

Objectives

To evaluate the in vitro antimicrobial/antivirulence action of bovine lactoferrin and its ability to synergize with levofloxacin against resistant Helicobacter pylori strains and to analyse the effect of levofloxacin, amoxicillin and esomeprazole with and without bovine lactoferrin as the first-line treatment for H. pylori infection.

Methods

The bovine lactoferrin antimicrobial/antivirulence effect was analysed in vitro by MIC/MBC determination and twitching motility against six clinical H. pylori strains and a reference strain. The synergism was evaluated using the chequerboard assay. The prospective therapeutic trial was carried out on two separate patient groups, one treated with esomeprazole/amoxicillin/levofloxacin and the other with esomeprazole/amoxicillin/levofloxacin/bovine lactoferrin. Treatment outcome was determined with the [¹³C]urea breath test.

Results

In vitro, bovine lactoferrin inhibited the growth of 50% of strains at 10 mg/mL and expressed 50% bactericidal effect at 40 mg/mL. The combination of levofloxacin and bovine lactoferrin displayed a synergistic effect for all strains, with the best MIC reduction of 16- and 32-fold for levofloxacin and bovine lactoferrin, respectively. Bovine lactoferrin at one-fourth MIC reduced microbial motility significantly for all strains studied. In the in vivo study, 6 of 24 patients recruited had treatment failure recorded with esomeprazole/amoxicillin/levofloxacin (75% success, 95% CI 57.68%–92.32%), and in the group with esomeprazole/amoxicillin/levofloxacin/bovine lactoferrin, 2 out of 53 patients recruited had failure recorded (96.07% success, 95% CI 90.62%–101.38%).

Conclusions

Bovine lactoferrin can be considered a novel potentiator for restoring susceptibility in resistant H. pylori strains. Bovine lactoferrin added to a triple therapy in first-line treatment potentiates the therapeutic effect.

Lead Molecules for Targeted Urease Inhibition: An Updated Review from 2010 -2018

The field of enzyme inhibition is a tremendous and quickly growing territory of research. Urease a nickel containing metalloenzyme found in bacteria, algae, fungi, and plants brings hydrolysis of urea and plays important role in environmental nitrogen cycle. Apart from this it was found to be responsible for many pathological conditions due to its presence in many microorganisms such as H. Pylori, a ureolytic bacteria having urease which elevates pH of gastric medium by hydrolyzing urea present in alimentary canal and help the bacteria to colonize and spread infection. Due to the infections caused by the various bacterial ureases such as Bacillus pasteurii, Brucella abortus, H. pylori, H. mustelae, Klebsiella aerogenes, Klebsiella tuberculosis, Mycobacterium tuberculosis, Pseudomonas putida, Sporosarcina pasteurii and Yersinia enterocolitica, it has been the current topic of today's research. About a wide range of compounds from the exhaustive literature survey has been discussed in this review which is enveloped into two expansive classes, as Inhibitors from synthetic origin and Inhibitors from natural origin. Moreover active site details of enzyme, mechanism of catalysis of substrate by enzyme, uses of plant urease and its pathogenic behavior has been included in the current review. So, overall, this review article diagrams the current landscape of the developments in the improvements in the thriving field of urease inhibitory movement in medicinal chemistry from year 2010 to 2018, with an emphasis on mechanism of action of inhibitors that may be used for more development of recent and strong urease inhibitors and open up new doors for assist examinations in a standout amongst the most lively and promising regions of research.

Management of Antibiotic-Resistant Helicobacter pylori Infection: Perspectives from Vietnam

Antibiotic resistance is the most important factor leading to the failure of eradication regimens. This review focuses on the prevalence of Helicobacter pylori primary and secondary resistance to clarithromycin, metronidazole, amoxicillin, levofloxacin, tetracycline, and multidrug in Vietnam. We searched the PubMed, EMBASE, Vietnamese National Knowledge Infrastructure, and Vietnamese Biomedical databases from January 2000 to December 2016. The search terms included the following: H. pylori infection, antibiotic (including clarithromycin, metronidazole, amoxicillin, levofloxacin, tetracycline, and multidrug) resistance in Vietnam. The data were summarized in an extraction table and analyzed manually. Finally, Excel 2007 software was used to create charts. Ten studies (three studies in English and seven in Vietnamese) were included in this review. A total of 308, 412, 523, 408, 399, and 268 H. pylori strains were included in this review to evaluate the prevalence of H. pylori primary resistance to amoxicillin, clarithromycin, metronidazole, levofloxacin, tetracycline, and multidrug resistance, respectively. Overall, the primary resistance rates of amoxicillin, clarithromycin, metronidazole, levofloxacin, tetracycline, and multidrug resistance were 15.0%, 34.1%, 69.4%, 27.9%, 17.9% and 48.8%, respectively. Secondary resistance rates of amoxicillin, clarithromycin, metronidazole, levofloxacin, tetracycline, and multidrug resistance were 9.5%, 74.9%, 61.5%, 45.7%, 23.5% and 62.3%, respectively. In Vietnam, primary and secondary resistance to H. pylori is increasing over time and affects the effectiveness of H. pylori eradication.

Molecular detection and characterization of mutation on 23S rRNA gene associated with clarithromycin resistant in Helicobacter pylori.. [DOI: 10.1101/650432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background

Helicobacter pylori consider as pathogenic resistant bacterium was colonized mainly in stomach and causing a prolonged gastritis with gastric ulcers were progressing to gastric carcinoma. Also its resistance to antibiotic considered as the main reason for failure to eradicate of this pathogen has been difficult when this resistance occurred as mutant on protein binding site in 23s ribosomal RNA. The highest cure rates have required multidrug antimicrobial therapies including combinations of omeprazole, clarithromycin and metronidazole.

Result

Bacterial DNA sequence from gastritis patients with confirmed previous positive ICT samples (Stool and Bloo) were used to obtain co-related between phenotypic & genotypic variant outcome have been observed as SNPs carried on nucleotides which could be altered protein prediction as result of that caused chronic gastritis incline to gastric carcinoma due to abnormal consequence on genetic level in H. species (23s rRNA) was referred to clarithromycin resistance, was achieved on this cross-sectional studies by running two different primers were amplify in PCR machine, first one for urease producing gene (Glm as universal primer) and second one for 23s rRNA as specific primer (rp1/fp1). Two samples out of Four samples were amplified as final isolate in the first cycle and have a specific band in 23s rRNA (NO.11, NO.24) as further DNA samples investigation were sent to get our target sequence.

Conclusion

Bioinformatics tools used to confirm a specific types of mutations give specific position responsible for bacteriostatic activity of macrolides such as clarithromycin depends on capacity to inhibit protein synthesis by binding to the 23S ribosomal subunit (23S rRNA) as resistant gene. The detection tools as MSA (multiple sequence alignment) for our nucleotides sequence to (11&24) samples with Genbank accession number 24_MK208582 and 11_MK208583. One type of mutation has been observed in nucleotide sequence (sample-24) in position 2516 (1344 _complementary) sequence result compared with reference sequence standard reference strain (H. pylori U27270) was confirmed which consider it as novel mutation in database for 23S rRNA Gene of H. pylori associated with Clarithromycin Resistance gene in Sudanese patients.

Therapeutic efficacy of pretreatment with compound Acidophilus lactob-acillus tablets followed by quadruple therapy in gastric ulcer patients with Helicobacter pylori infection

AIM

To evaluate the efficacy of pretreatment with compound Acidophilus lactobacillus tablets followed by quadruple therapy in gastric ulcer patients with Helicobacter pylori (H. pylori) infection.

METHODS

One hundred and eighty patients with gastric ulcer associated with H. pylori infection treated at Department of Gastroenterology, Lishui City People's Hospital, from June 2015 to December 2017 were selected. All patients were diagnosed by gastroscopy and carbon-14 breath test positive. The patients were randomly divided into three groups: A, B, and C (60 cases each). All groups received pantoprazole 40 mg, amoxicillin 1.0 g, clarithromycin 500 mg, colloidal bismuth capsules 200 mg twice a day for 2 wk, followed by treatment with pantoprazole 20 mg once a day for 6 wk. Group B was additionally given compound Lactobacillus acidophilus tablets three times a day for the initial 2 wk. Group C was given compound Lactobacillus acidophilus tablets three times a day for 2 wk before quadruple therapy. The effective rate for ulcer, eradication rate of H. pylori, and the incidence of adverse reactions at 2 mo after treatment were compared among the three groups.

RESULTS

The effective rates for ulcer in groups A, B, and C were 73.3%, 88.3%, and 93.3%, respectively; the effective rates in groups B and C were significantly higher than that of group A (P < 0.05). The eradication rates of H. pylori in groups A, B, and C were 65.00%, 80.00%, and 91.67%, respectively; the eradication rate was significantly higher in groups B and C than in group A (P < 0.05), and in group C than in group B (P < 0.05). The incidence rates of adverse reactions in groups A, B, and C were 16.67%, 8.33%, and 6.67%, respectively; the incidence rates in groups B and C were significantly lower than that of group A (P < 0.05), although there was no significant difference between groups B and C (P > 0.05).

CONCLUSION

Pretreatment with compound Acidophilus lactobacillus tablets for 2 wk followed by quadruple therapy in gastric ulcer patients with H. pylori infection can effectively improve the eradication rate of H. pylori and reduce adverse drug reactions.

Prevalence of Primary Antimicrobial Resistance of H. pylori in Turkey: A Systematic Review

BACKGROUND

The prevalence of clarithromycin resistance has increased to the 20% or more in different regions of the world. Clarithromycin resistance is known to be responsible for most of the treatment failures in Helicobacter pylori (H. pylori) infection. The aim of this systematic review was to summarize the prevalence of primary antibiotic resistance (amoxicillin, clarithromycin, metronidazole, levofloxacin, tetracycline) of H. pylori strains in different geographical regions of Turkey.

MATERIAL AND METHODS

An Internet search was performed using PubMed and the ULAKBIM Turkish Medical Database. The terms "primary antibiotic resistance (separately; amoxicillin, clarithromycin, metronidazole, levofloxacin, tetracycline) of H. pylori" with and without "Turkey" or "different geographical regions of Turkey" were searched among articles published in both English and Turkish language within the time span from 1999 to 2015. Data analysis was performed using MedCalc 12.7.0. Each article was weighted according to the number of isolated H. pylori strains. Pooled proportion analysis was performed.

RESULTS

Twenty-one Turkish studies including 1059 H. pylori strains were included in this review. The overall primary antibiotic resistance rates of H. pylori strains isolated in Turkey were as follows: amoxicillin 3 (0.971%), clarithromycin 425 (24.864%), metronidazole 75 (33.747%), tetracycline 2 (3.511%), and levofloxacin 31 (23.769%).

CONCLUSIONS

Primary antibiotic resistance against H. pylori in Turkey shows differences between geographical regions and population densities. There is an increase in primary resistance rates to clarithromycin and metronidazole in different years. The data are not sufficient for tetracycline, amoxicillin, and levofloxacin. High clarithromycin resistance rates were mostly detected in overpopulated cities like Ankara (north), Izmir (west), Istanbul (west), and Bursa (west).

Antimicrobial resistance of Helicobacter pylori strains to five antibiotics, including levofloxacin, in Northwestern Turkey

INTRODUCTION

Antibiotic resistance is the main factor that affects the efficacy of current therapeutic regimens against Helicobacter pylori. This study aimed to determine the rates of resistance to efficacy clarithromycin, amoxicillin, tetracycline, levofloxacin and metronidazole among H. pylori strains isolated from Turkish patients with dyspepsia.

METHODS

H. pylori was cultured from corpus and antrum biopsies that were collected from patients with dyspeptic symptoms, and the antimicrobial susceptibility of H. pylori was determined using the E-test (clarithromycin, amoxicillin, tetracycline, metronidazole and levofloxacin) according to the EUCAST breakpoints. Point mutations in the 23S rRNA gene of clarithromycin-resistant strains were investigated using real-time PCR.

RESULTS

A total of 98 H. pylori strains were isolated, all of which were susceptible to amoxicillin and tetracycline. Of these strains, 36.7% (36/98) were resistant to clarithromycin, 35.5% (34/98) were resistant to metronidazole, and 29.5% (29/98) were resistant to levofloxacin. Multiple resistance was detected in 19.3% of the isolates. The A2143G and A2144G point mutations in the 23S rRNA-encoding gene were found in all 36 (100%) of the clarithromycin-resistant strains. Additionally, the levofloxacin MIC values increased to 32 mg/L in our H. pylori strains. Finally, among the clarithromycin-resistant strains, 27.2% were resistant to levofloxacin, and 45.4% were resistant to metronidazole.

CONCLUSIONS

We conclude that treatment failure after clarithromycin- or levofloxacin-based triple therapy is not surprising and that metronidazole is not a reliable agent for the eradication of H. pylori infection in Turkey.

Quinolone-based first, second and third-line therapies for Helicobacter pylori

Helicobacter pylori (H. pylori) is a very common bacterium that infects about 50% of the world population in urban areas and over 90% of people living in rural and developing countries. Fluoroquinolones, a class of antimicrobials, have been extensively used in eradication regimens for H. pylori. Levofloxacin is the most commonly used, and in second-line regimens, is one of the most effective options. However, an increasing resistance rate of H. pylori to fluoroquinolones is being observed, that will likely affect their effectiveness in the near future. Other novel fluoroquinolone molecules, such as moxifloxacin, sitafloxacin, gatifloxacin and gemifloxacin, have been proposed and showed encouraging results in vitro, although data on their clinical use are still limited. Further studies in large sample trials are needed to confirm their safety and efficacy profile in clinical practice.

Comparison of levofloxacin- and moxifloxacin-based triple therapies with standard treatment in eradication of Helicobacter pylori as first-line therapy

AIM

It is recommended that treatments that include clarithromycin should be avoided in eradication of Helicobacter pylori (HP) in cases where clarithromycin resistance is higher than 20%. We aimed to compare levofloxacin- and moxifloxacin-based triple therapies with standard treatment and with each other in eradication of helicobacter pylori as first-line therapy.

MATERIALS AND METHODS

Patients were randomized prospectively as three groups. There were 102 patients in the levofloxacin group, 101 patients in the moxifloxacin group, and 103 patients in the standard treatment group. The patients received levofloxacin 500 mg daily, amoxicillin 1 g b.i.d. and lansoprazole 30 mg b.i.d. for ten days (LAL) in the levofloxacin group; moxifloxacin 400 mg daily, amoxicillin 1 g b.i.d. and lansoprazole 30 mg b.i.d. (MAL) in the moxifloxacin group; and clarithromycin 500 mg b.i.d., amoxicillin 1 g b.i.d. and lansoprazole 30 mg b.i.d. (CAL) in the standard treatment group. At post-treatment week 6, HP was checked by using stool antigen test.

RESULTS

In the eradication of Helicobacter pylori, the success rate as determined by per protocol (PP) analysis was 92% in the LAL group, 91.8% in the MAL group, and 82.4% in the CAL group. A statistically significant difference was found in the LAL and MAL groups compared to the CAL group (p < 0.05). There was no difference between the LAL and MAL groups.

CONCLUSIONS

It was determined that levofloxacin- and moxifloxacin-based triple therapies were more effective than the standard treatment in first-line setting in the eradication of Helicobacter pylori. In addition, no difference was found between levofloxacin- and moxifloxacin-based triple therapies. Currently observed high efficacy may be evaluated in treatment. Although quinolon resistance is not considered a major problem, it appears to be a factor that may reduce treatment success over a period of time.

First-line eradication rates comparing two shortened non-bismuth quadruple regimens against Helicobacter pylori: an open-label, randomized, multicentre clinical trial

OBJECTIVES

Helicobacter pylori eradication remains a challenge. Non-bismuth-based quadruple regimens (NBQR) have shown high eradication rates (ER) elsewhere that need to be locally confirmed. The objective of this study was to compare the first-line ER of a hybrid therapy (20 mg of omeprazole twice daily and 1 g of amoxicillin twice daily for 10 days, adding 500 mg of clarithromycin twice daily and 500 mg of metronidazole every 8 h for the last 5 days; OA-OACM) with that of a 10 day concomitant regimen consisting of taking all four drugs twice daily every day (including 500 mg of metronidazole every 12 h; OACM). A 10 day arm with standard triple therapy (OAC; 20 mg of omeprazole/12 h, 1 g of amoxicillin/12 h and 500 mg of clarithromycin/12 h) was included.

PATIENTS AND METHODS

Three hundred consecutive patients were randomized (1: 2: 2) into one of the three following regimens: (i) OAC (60); (ii) OA-OACM (120); and (iii) OACM (120). Eradication was generally confirmed by a [(13)C]urea breath test at least 4 weeks after the end of treatment. Adverse events and compliance were assessed. EudraCT: 2011-006258-99.

RESULTS

ITT cure rates were: OAC, 70.0% (42/60) (95% CI: 58.3-81.7); OA-OACM, 90.8% (109/120) (95% CI: 85.6-96.0); and OACM, 90.0% (107/119) (95% CI: 84.6-95.4). PP rates were: OAC, 72.4% (42/58) (95% CI: 60.8-84.1); OA-OACM, 93.9% (108/115) (95% CI: 89.5-98.3); and OACM, 90.3% (102/113) (95% CI: 84.8-95.8). Both NBQR significantly improved ER compared with OAC (P < 0.01), but no differences were seen between them. Mean compliance was elevated [98.0% (SD = 9.8)] with no differences between groups. There were more adverse events in the quadruple arms (OACM, 65.8%; OA-OACM, 68.6%; OAC, 46.6%; P < 0.05), but no significant differences between groups in terms of severity were seen.

CONCLUSIONS

Hybrid and concomitant regimens show good ER against H. pylori infection with an acceptable safety profile. They clearly displace OAC as first-line regimen in our area.

Is There Any Advantage of Treating Partners in Helicobacter pylori Eradication?

Aim. We designed this trial to find answers to the following questions. (1) Does the success rate decrease in a country where HP prevalence is high? (2) Can we provide benefit by simultaneously treating the partners of infected patients? Materials and Methods. The first group consisted of 102 HP-positive patients, and both the patients and their HP-positive partners were treated. The second group consisted of 104 HP-positive patients whose partners were HP-positive but only the patients were treated. The participants in both groups were treated with levofloxacin 500 mg daily, amoxicillin 1 g b.i.d, and lansoprazole 30 mg b.i.d (LAL) for ten days. Results. In the per-protocol analysis, the eradication success rate was found to be 92.2% (94/8) in the first group and 90.4% (94/10) in the second group. No statistically significant difference was found between the two groups (P > 0.05). Conclusions. With regard to the HP eradication rate, no difference was found between treating the HP-positive partners of HP-positive patients simultaneously and not treating them simultaneously. According to these results, we can say that reinfections between partners do not significantly contribute to the failure of eradication.

Fluoroquinolone-based protocols for eradication of Helicobacter pylori

Helicobacter pylori (H. pylori) is a widespread pathogen infecting about 40% of people living in urban areas and over 90% of people living in the developing regions of the world. H. pylori is well-documented as the main factor in the pathogenesis of peptic ulcer disease, chronic gastritis, and gastric malignancies such as cancer and mucosa-associated lymphoid tissue-lymphoma; hence, its eradication is strongly recommended. The Maastricht IV consensus, which focused on the management of H. pylori infection, set important new strategies in terms of treatment approaches, particularly with regards to first- and second-line treatment protocols and led to improved knowledge and understanding of H. pylori resistance to antibiotics. In recent years, various fluoroquinolone-based protocols, mainly including levofloxacin, have been proposed and effectively tested at all therapeutic lines for H. pylori eradication. The aim of the present paper is to review the scientific literature focused on the use of fluoroquinolones in eradicating H. pylori.

Is levofloxacin-based triple therapy an alternative for first-line eradication of Helicobacter pylori? A systematic review and meta-analysis

OBJECTIVES

To evaluate the available data on the efficacy and safety of levofloxacin-based triple therapy compared with standard triple therapy in first-line treatment for Helicobacter pylori infection.

METHODS

By searching MEDLINE, The Cochrane Central Register of Controlled Trials, and Web of Knowledge, two independent reviewers systemically identified randomized controlled trials comparing levofloxacin-based triple regimen with standard triple therapy for first-line treatment of H. pylori infection. The pooled risk ratios (RR) and 95% confidence intervals were calculated.

RESULTS

Overall, nine randomized controlled trials including 1275 patients have been treated with levofloxacin-based triple therapy and 1237 patients with standard regimen. Eradication rate in the levofloxacin-based therapy group was slightly higher than that in the standard triple therapy group regardless of treatment duration (80.2% vs. 77.4%, RR=1.03, 95% CI=0.94-1.13). Subgroup analysis related to different geographic areas found that efficacy of 7-day standard triple regimen was statistically superior to 7-day levofloxacin-based scheme in Asian group (RR=0.91, 95% CI=0.86-0.97), but levofloxacin-based triple therapy was predominant regardless of treatment time in European countries (RR=1.15, 95% CI=1.06-1.23). There was no significant difference between two groups in the incidence of overall adverse events or in the occurrence of discontinuing therapy due to side effects.

CONCLUSIONS

The 10-day levofloxacin-based triple therapy may be considered as an alternative for increasing cure rate of H. pylori infection in European areas. But in Asian countries, standard triple regimen is still superior to levofloxacin-based therapy as first-line regimen for H. pylori eradication.

Levofloxacin and proton pump inhibitor-based triple therapy versus standard triple first-line therapy for Helicobacter pylori eradication

BACKGROUND

Standard triple therapy for Helicobacter pylori infection fails in up to one quarter of patients. Levofloxacin-based triple therapy may be more efficacious.

OBJECTIVE

The aim of this paper was to compare levofloxacin and proton pump inhibitor-based triple therapy with standard triple therapy for H. pylori infection.

METHODS

PubMed, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar, and Ovid were systematically searched to identify randomized controlled trials comparing levofloxacin and proton pump inhibitor-based therapy with standard triple therapy in treatment-naive patients with H. pylori infection until August 2013.

RESULTS

Ten randomized controlled trials involving 2676 patients (1357 in the levofloxacin group and 1319 in the control group) met the inclusion criteria. The pooled odds ratio by intention-to-treat analysis and by per protocol analysis in the levofloxacin regimen versus standard regimen was 1.28 [95% confidence interval (CI): 0.88-1.85] and 1.23 (95% CI: 0.82-1.84) by the random effects model, respectively. There was no statistical significance of the incidence of total side effects between the groups, but levofloxacin-based therapy was associated with a significant reduction in the incidence of taste disturbance compared with standard third therapy.

CONCLUSION

Levofloxacin-based therapy was as safe and effective as triple therapy for H. pylori infection and could be considered as an additional treatment option. However, more rigorous research is required to accurately assess the role of levofloxacin in eradicating H. pylori infection.

Levofloxacin-based first-line therapy versus standard first-line therapy for Helicobacter pylori eradication: meta-analysis of randomized controlled trials

Background

First-line levofloxacin-based treatments eradicate Helicobacter pylori with varying success. We examined the efficacy and safety of first-line levofloxacin-based treatment in comparison to standard first-line therapy for H pylori eradication.

Materials and Methods

We searched literature databases from Medline, EMBASE, and the Cochrane Register of Randomized Controlled Trials through March 2013 for randomized controlled trials comparing first-line levofloxacin and standard therapy. We included randomized controlled trials conducted only on naïve H pylori infected patients in adults. A systematic review was conducted. Meta-analysis was performed with Review Manager 5.2. Treatment effect was determined by relative risk with a random or fixed model by the Mantel-Haenszel method.

Results

Seven trials were identified with 888 patients receiving 7 days of first-line levofloxacin and 894 treated with standard therapy (Amoxicillin, Clarithromycin and proton pump inhibitor) for 7 days. The overall crude eradication rate in the Levofloxacin group was 79.05% versus 81.4% in the standard group (risk ratio 0.97; 95% CI; 0.93, 1.02). The overall dropout was 46 (5.2%) in the levofloxacin group and 52 (5.8%) for standard therapy. The dizziness was more common among group who took Levofloxacin based treatment and taste disturbance was more common among group who took standard therapy. Meta-analysis of overall adverse events were similar between the two groups with a relative risk of 1.06 (95% CI 0.72, 1.57).

Conclusion

Helicobacter pylori eradication with 7 days of Levofloxacin-based first line therapy was safe and equal compared to 7 days of standard first-line therapy.

Helicobacter pylori: Future perspectives in therapy reflecting three decades of experience

The rising prevalence of antibiotic resistance has created a need to reassess the established Helicobacter pylori (H. pylori) eradication protocols, and to develop new ones. Various bacterial and host factors are evaluated, and their contribution to eradication failure is estimated. For a long time being considered the cornerstone eradication scheme, the standard triple therapy has been replaced with novel, more efficient regimens, namely sequential and concomitant, along with the emergence of a new design of bismuth quadruple therapy. A rescue levofloxacin based regimen has overcome the fear of therapy failure due to higher prevalence of dual resistant (clarithromycin and metronidazole) H. pylori. Culture-free and efficient susceptibility test are reestablishing the concept of tailored therapy, making eradication success close to originally desirable rates. Alleviating therapy side effects and improving patient compliance are as important as choosing appropriate eradication schemes, so various probiotic compound supplements are taken into consideration. Finally, we summarize the emerging efforts and obstacles in creating efficient H. pylori vaccine.

Treatment of Helicobacter pylori infection 2013

This review summarizes important studies regarding Helicobacter pylori therapy published from April 2012 up to March 2013. To begin with, the updated European Consensus Guidelines were published last year, highlighting the role of bismuth and nonbismuth quadruple regimen as first-line treatments. Cure rates for standard triple therapy remain acceptable in quite a few settings nowadays, and some reports on innovative triple therapies look promising. One study evaluating bismuth quadruple therapy as first-line therapy was reported. Regarding nonbismuth quadruple regimens, there is a trend of superiority emerging for the "concomitant" therapy over the "sequential" regimen. "Hybrid" therapy, a combination of sequential and concomitant therapy, has also shown advantage over sequential therapy. Levofloxacin-based therapies appear to be useful and versatile in second- and third-line therapies, with interesting results for newer generation quinolones, which may partially overcome antibiotic resistance. Some promising works have been reported for bismuth-based rescue therapy, using individualized therapies upon antimicrobial information, as well as for rifabutin fourth-line therapy. Probiotics appear to have an effect in terms of reducing side effects and improving compliance, but data on improvement of eradication rates remain controversial.

[Update on the efficacy of triple therapy for Helicobacter pylori infection and clarithromycin resistance rates in Spain (2007-2012)]

INTRODUCTION

Triple therapy, which remains the standard treatment for Helicobacter pylori infection, should be discouraged when its efficacy is lower than 80% or when clarithromycin resistance rates are above 15-20%.

AIM

To update the available evidence on the effectiveness of triple therapy and clarithromycin resistance rates in adults in Spain over the last 6 years.

METHODS

A literature search (2007-2012) was conducted in Medline and the abstracts books of the annual meetings of several Spanish gastroenterological and microbiological congresses. The search terms were « Helicobacter pylori », « Spain » and « clarithromycin ». Studies were selected if they included triple therapy consisting of a proton pump inhibitor with clarithromycin and amoxicillin or if they analyzed H. pylori clarithromycin susceptibility in treatment-naïve patients.

RESULTS

There were five articles and nine abstracts (3147 patients) on triple therapy, which showed a mean cure rate of 70.8% (95% CI = 66-76%). When stratified by the duration of therapy, the mean cure rates were 68.8% (60-76%) for 7-day regimens and 71.76% (68-78%) for 10-day regimens. For clarithromycin resistance rates, four articles and five abstracts (1709 patients) revealed a mean resistance rate of 18.3% (13-22%).

CONCLUSIONS

The efficacy of triple therapy seems to be unacceptable in recent studies conducted in Spain, possibly associated with clarithromcyin resistance rates higher than previously reported.