Sequential vs. prolonged 14-day triple therapy for Helicobacter pylori eradication: the meta-analysis may be influenced by 'geographical weighting'

Practice guidelines for the management of Helicobacter pylori infection: The Saudi H. pylori Working Group recommendations

The eradication rates for Helicobacter pylori globally are decreasing with a dramatic increase in the prevalence of antibiotic resistant bacteria all over the world, including Saudi Arabia. There is no current consensus on the management of H. pylori in Saudi Arabia. The Saudi Gastroenterology Association developed these practice guidelines after reviewing the local and regional studies on the management of H. pylori. The aim was to establish recommendations to guide healthcare providers in managing H. pylori in Saudi Arabia. Experts in the areas of H. pylori management and microbiology were invited to write these guidelines. A literature search was performed, and all authors participated in writing and reviewing the guidelines. In addition, international guidelines and consensus reports were reviewed to bridge the gap in knowledge when local and regional data were unavailable. There is limited local data on treatment of H. pylori. The rate of clarithromycin and metronidazole resistance is high; therefore, standard triple therapy for 10-14 days is no longer recommended in the treatment of H. pylori unless antimicrobial susceptibility testing was performed. Based on the available data, bismuth quadruple therapy for 10-14 days is considered the best first-line and second-line therapy. Culture and antimicrobial susceptibility testing should be considered following two treatment failures. These recommendations are intended to provide the most relevant evidence-based guidelines for the management of H. pylori infection in Saudi Arabia. The working group recommends further studies to explore more therapeutic options to eradicate H. pylori.

7-day versus 14-day tegoprazan-based triple therapy to treat Helicobacter pylori infection: Real-world evidence

BACKGROUND AND AIM

Potassium-competitive acid blockers (P-CABs) can be used to eradicate Helicobacter pylori infection. We aimed to evaluate the impact of treatment duration (7 vs 14 days) on successful H. pylori eradication with P-CAB-based triple therapy in Korea, where clarithromycin resistance rate is high.

METHODS

We retrospectively reviewed the data of patients who received first-line treatment for H. pylori infection with tegoprazan-based triple therapy (50 mg tegoprazan + 1000 mg amoxicillin + 500 mg clarithromycin twice daily for 1 or 2 weeks). The primary endpoint was the eradication rate in intention-to-treat (ITT) analysis.

RESULTS

Of the 948 patients included in the study, 435 and 513 received 7-day and 14-day tegoprazan-based triple therapy, respectively. The eradication rate was higher in the 14-day therapy group than in the 7-day therapy group (ITT, 63.9%; 95% confidence interval [CI], 59.3-68.3%] vs 78.6% [95% CI, 74.9-81.9%], respectively, P < 0.001; per-protocol, 70.5% [95% CI, 65.8-74.8%] vs 85.1% [81.7-88.1%], respectively, P < 0.001). Overall adverse event rates did not differ between the two groups. Although six patients in the 14-day treatment group discontinued the prescribed medications due to adverse events, four of them (67%) discontinued the medication within 4 days.

CONCLUSIONS

The 14-day tegoprazan-based triple therapy showed a superior eradication rate and acceptable adverse events compared with the 7-day tegoprazan-based triple therapy. A 14-day treatment regimen may be required when H. pylori infection is treated with tegoprazan-based triple therapy in regions with high clarithromycin resistance.

Effect of metronidazole resistance on Helicobacter pylori eradication regimens

OBJECTIVES

Guidelines suggest bismuth-containing quadruple therapy (BQT) or concomitant therapy (CT) as first-line therapy in our geographic area. Both schedules contain metronidazole. We aimed to evaluate the effect of metronidazole resistance to Helicobacter pylori (H. pylori) eradication therapy.

METHODS

We recruited treatment-naïve subjects with H. pylori infection who received either CT or BQT during January 2020 and December 2021. Before therapy, a fecal sample was collected using the THD fecal test device from each patient. H. pylori DNA was extracted and mutations of rdxA and frxA genes and A2143G for metronidazole and clarithromycin resistance were investigated using real-time polymerase chain reaction with a high-resolution melting curve.

RESULTS

Ninety-six patients were enrolled, including 29 received BQT and 67 received CT. The overall eradication rate was 94.8% (100% for BQT and 92.5% for CT). Metronidazole resistance was found in 18 (18.8%) subjects, while clarithromycin resistance was found in 19 (19.8%). All 18 patients with metronidazole resistance achieved successful eradication (five treated with BQT and 13 with CT). The eradication rate in metronidazole-sensitive strains was 93.6%. Of these, 24 received BQT with 100% success, and 54 had CT with five failures (successful eradication in 90.7%). Two patients with treatment failure were resistant to clarithromycin, and the remaining three were susceptible to both clarithromycin and metronidazole. No statistical significance was observed in the eradication rate between metronidazole-resistant and -sensitive strains (100% vs 93.6%, P = 0.58).

CONCLUSION

Metronidazole resistance does not influence the eradication rate of BQT and CT regimens in our geographical area, even if such results need to confirmed in a larger sample.

The Emergence of Multidrug-Resistant Helicobacter pylori in Southeast Asia: A Systematic Review on the Trends and Intervention Strategies Using Antimicrobial Peptides

The emergence of multidrug-resistant H. pylori poses a public healthcare threat, particularly in low- and middle-income countries. Recently, the World Health Organization has classified clarithromycin-resistant H. pylori as high priority in the research and discovery of novel antibiotics. This study was aimed to systematically review the prevalence of primary antibiotic resistance in H. pylori in Southeast Asian countries (SEAC) and to review current studies of antimicrobial peptides against H. pylori. We systematically searched through electronic databases of studies conducted on antimicrobial resistance of H. pylori in SEA countries. Furthermore, we searched articles that conducted studies on antimicrobial peptides, naturally occurring host’s defense molecules, against H. pylori. After a series of screening processes, 15 studies were included in our systematic review. Our analysis revealed that primary resistance of H. pylori to metronidazole, clarithromycin, and levofloxacin were high in SEAC, although the primary resistance to amoxicillin and tetracycline remains low. Multidrug-resistant H. pylori are emerging in SE Asian countries. The antimicrobial peptides show promising antibacterial and antibiofilm activity against drug-resistant H. pylori. The research and discovery of antimicrobial peptides against H. pylori in SEAC will help in limiting the spread of antimicrobial resistance of H. pylori.

Efficacy and safety of bismuth-containing quadruple treatment and concomitant treatment for first-line Helicobacter pylori eradication: A systematic review and meta-analysis

Bismuth-containing quadruple treatment (BQT) and concomitant treatment (CT) were recommended as alternative first-line treatments of Helicobacter pylori (H. Pylori). A meta-analysis was performed to evaluate the cure rates and compare efficacy and safety of BQT and CT for H. Pylori eradication. PubMed, Cochrane Library, and Embase databases were searched on June 16, 2020. Meta-analysis, sensitivity analysis, and subgroup analysis were conducted by Review Manager 5.3 and Stata 11.0. Ten studies were collected. We found no difference of cure rate between BQT and CT in intention-to-treat (ITT) analysis (84.6% vs. 82.9%, OR = 1.14, 95% CI: 0.94-1.38; P = 0.19) and marginally statistical difference in per-protocol (PP) analysis (92.4% vs 90.1%, OR = 1.32, 95% CI: 1.00-1.73; P = 0.05). Based on the results of subgroup analyses, we found statistical difference of eradication rate between BQT and CT (amoxicillin + clarithromycin + metronidazole + PPI treatment) according to PP analysis (94.3% vs. 91.5%, OR = 1.49, 95% CI:1.03-2.15; P = 0.03) and marginally statistical difference according to ITT analysis (87.5% vs. 84.6%, OR = 1.28, 95% CI:1.00-1.65; P = 0.05). BQT and CT may be both good treatment options for H. pylori infection. However, BQT was superior to current scheme of CT (amoxicillin + clarithromycin + metronidazole + PPI treatment) in subgroup analysis. It is very necessary to choose tailored therapy as an outstanding way to reduce the impact of antibiotic.

Helicobacter pylori Primary and Secondary Genotypic Resistance to Clarithromycin and Levofloxacin Detection in Stools: A 4-Year Scenario in Southern Italy

Antibiotic resistance has become an emerging problem for treating Helicobacter pylori (H. pylori) infection. Clarithromycin and levofloxacin are two key antibiotics used for its eradication. Therefore, we reviewed our experience with genotypic resistance analysis in stools to both clarithromycin and levofloxacin in the last four years to evaluate time trends, both in naive and failure patients. Patients collected a fecal sample using the THD fecal test device. Real-time polymerase chain reaction was performed to detect point mutations conferring resistance to clarithromycin (A2142C, A2142G, and A2143G in 23S rRNA) and levofloxacin (substitutions at amino acid position 87 and 91 of gyrA). One hundred and thirty-five naive patients were recruited between 2017-2020. Clarithromycin resistance was detected in 37 (27.4%). The time trend did not show any significant variation from 2017 to 2020 (p = 0.33). Primary levofloxacin resistance was found in 26 subjects (19.2%), and we observed a dramatic increase in rates from 2017 (10%) to 2018 (3.3%), 2019 (20%), and 2020 (37.8%). Ninety-one patients with at least one eradication failure were recruited. Secondary resistance to clarithromycin and levofloxacin was found in 59 (64.8%) and 45 patients (59.3%), respectively. In conclusion, our geographic area has a high risk of resistance to clarithromycin. There is also a progressive spreading of levofloxacin-resistant strains.

Helicobacter pylori treatment in Turkey: Current status and rational treatment options

According to the TURHEP study, the prevalence of Helicobacter pylori in Turkey is 82.5%. After FDA approval in 1995, many countries have used standard triple therapy (proton pump inhibitor 40 mg b.i.d clarithromycin 500 mg b.i.d and amoxicillin 1 gr b.i.d) for Helicobacter pylori treatment. In the beginning, eradication rates were above 90% in many countries; however, current studies have demonstrated a prominent decrease in successful treatment rates, even down to 60%. This unfavorable reduction stimulated searches for new treatment protocols. Treatment protocols differ according to country, prevalence, cost-effectiveness, antibiotic resistance, CYP2C19 polymorphism and eradication rates. Thus, each country/region needs to revise its own therapeutic results and the efficacy of various eradication regimens in the treatment of Helicobacter pylori. This report aims to review the current status of Helicobacter pylori treatment in Turkey and to provide recommendations for rational therapeutic considerations for the eradication of the bacterium.

Comparison of the efficacy and safety of hybrid and sequential therapies as a first-line regimen for Helicobacter pylori infection in Turkey

INTRODUCTION

Helicobacter pylori infection is a common infection worldwide. The most frequently recommended treatment for eradication of H. pylori remains triple therapy. In this study, we compared sequential and hybrid regimens for H. pylori eradication in a region of Turkey with high resistance to clarithromycin.

MATERIAL AND METHODS

Three hundred and forty H. pylori-positive patients were enrolled in the study. The subjects were randomly divided into two groups. The first group (170 patients) received rabeprazole (40 mg/b.i.d.) and amoxicillin (1000 mg/b.i.d.) for 2 weeks and metronidazole and clarithromycin (500 mg/b.i.d.) during the second week in the hybrid therapy group. The second group (170 patients) received rabeprazole (40 mg/b.i.d.) for 14 days, amoxicillin (1000 mg/b.i.d.) for the first 7 days, and metronidazole plus clarithromycin (each 500 mg/b.i.d.) during the next 7 days in the sequential therapy group.

RESULTS

In the per-protocol analysis, the eradication rate in the hybrid therapy group was 96.1% (147/153), and in the sequential therapy group it was 90.9% (140/154). There was no significant difference between the two groups (p = 0.06). Ninety-seven of those 340 patients reported minor adverse drug reactions. The percentages of patients with adverse reactions were 30.6% in the hybrid therapy group and 26.5% in the sequential therapy group (p = 0.74).

CONCLUSIONS

Both therapies are highly effective for eradication of H. pylori, and could be recommended as a first-line therapy in regions with high antibiotic resistance.

Probiotic monotherapy and Helicobacter pylori eradication: A systematic review with pooled-data analysis

AIM

To define probiotic monotherapy effect on Helicobacter pylori (H. pylori) status by performing a systematic review.

METHODS

Methods of analysis and inclusion criteria were based on PRISMA recommendations. Relevant publications were identified by searching PubMed, MEDLINE, Science Direct, and EMBASE. The end-point was to estimate eradication rate and urea breath test delta value before and after probiotic monotherapy across all studies and, overall, with a pooled data analysis. Adverse events of probiotic therapy were evaluated. The data were expressed as proportions/percentages, and 95%CIs were calculated. For continuous variables, we evaluated the weighted mean difference. Odd ratios (ORs) were calculated according to the Peto method for the comparison of eradication rates between probiotics and placebo.

RESULTS

Eleven studies were selected. Probiotics eradicated H. pylori in 50 out of 403 cases. The mean weighted eradication rate was 14% (95%CI: 2%-25%, P = 0.02). Lactobacilli eradicated the bacterium in 30 out of 235 patients, with a mean weighted rate of 16% (95%CI: 1%-31%). Saccharomyces boulardii achieved eradication in 6 out of 63 patients, with a pooled eradication rate of 12% (95%CI: 0%-29%). Multistrain combinations were effective in 14 out of 105 patients, with a pooled eradication rate of 14% (95%CI: 0%-43%). In the comparison of probiotics vs placebo, we found an OR of 7.91 in favor of probiotics (95%CI: 2.97-21.05, P < 0.001). Probiotics induced a mean reduction in delta values higher than placebo (8.61% with a 95%CI: 5.88-11.34, vs 0.19% for placebo, P < 0.001). Finally, no significant difference in adverse events was found between probiotics and placebo (OR = 1, 95%CI: 0.06-18.08).

CONCLUSION

Probiotics alone show a minimal effect on H. pylori clearance, thus suggesting a likely direct role.

Efficacy of Helicobacter pylori eradication therapies in Korea: A systematic review and network meta-analysis

BACKGROUND

The efficacy of Helicobacter pylori eradication regimens may depend on the country where the studies were performed because of the difference in antibiotic resistance. We aimed to analyze the efficacy of H. pylori eradication regimens in Korea where clarithromycin resistance rate is high.

METHODS

We searched for all relevant randomized controlled trials published until November 2016 that investigated the efficacy of H. pylori eradication therapies in Korea. A network meta-analysis was performed to calculate the direct and indirect estimates of efficacy among the eradication regimens.

RESULTS

Forty-three studies were identified through a systematic review, of which 34 studies, published since 2005, were included in the meta-analysis. Among 21 included regimens, quinolone-containing sequential therapy for 14 days (ST-Q-14) showed the highest eradication rate (91.4% [95% confidence interval [CI], 86.9%-94.4%] in the intention-to-treat [ITT] analysis). The eradication rate of the conventional triple therapy for 7 days, standard sequential therapy for 10 days, hybrid therapy for 10-14 days, and concomitant therapy for 10-14 days was 71.1% (95% CI, 68.3%-73.7%), 76.2% (95% CI, 72.8%-79.3%), 79.4% (95% CI, 75.5%-82.8%), and 78.3% (95% CI, 75.3%-80.9%), respectively, in the ITT analysis. In the network meta-analysis, ST-Q-14 showed a better comparative efficacy than the conventional triple therapy, standard sequential therapy, hybrid therapy, and concomitant therapy. In addition, tolerability of ST-Q-14 was comparable to those regimens.

CONCLUSION

In Korea, ST-Q-14 showed the highest efficacy in terms of eradication and a comparable tolerability, compared to the results reported for the conventional triple therapy, standard sequential therapy, hybrid therapy, and concomitant therapy.

First-line therapies for Helicobacter pylori eradication: a critical reappraisal of updated guidelines

Helicobacter pylori (H. pylori) treatment remains a challenge for the clinician, as no available therapy is able to cure the infection in all treated patients. In the last two decades, several antibiotic combinations have been proposed, including triple therapies, bismuth-free therapies (sequential, concomitant, hybrid regimens), and bismuth-based quadruple therapy. Some national and international guidelines on H. pylori management have recently been updated, recommending or discouraging the use of each of these therapeutic approaches, based mainly on the presumed pattern of primary antibiotic resistance in different geographic areas. We examined the recommendations on first-line therapies in the most recently updated guidelines worldwide, taking into account other data affecting the efficacy of a therapy regimen beyond the primary resistance pattern. Although several guidelines highlighted that the results achieved by an eradication therapy are population-specific and not directly transferable, it emerged that some therapy regimens are recommended or discouraged with no mention of the vital need for national data.

Helicobacter pylori DNA isolation in the stool: an essential pre-requisite for bacterial noninvasive molecular analysis

PURPOSE

Real-time polymerase chain reaction (RT-PCR) is a widely used technique for bacterial and viral infection diagnosis. Herein, we report our preliminary experience in retrieving H. pylori genetic sequences in stools and analyzing genotypic clarithromycin resistance by RT-PCR (noninvasive), with the aim of comparing this procedure with that performed on biopsy samples (invasive).

MATERIALS AND METHODS

After 'in vitro' demonstration of H. pylori DNA detection from pure and stool-mixed bacteria, 52 consecutive patients at the first diagnosis of infection were investigated. DNA was extracted from biopsy tissue and stool samples (THD^® Fecal Test, Italy). RT-PCR was performed to detect 23S rRNA encoding bacterial subunit gene and search A2143G, A2142C, A2142G point mutations for clarithromycin resistance assessment.

RESULTS

RT-PCR showed H. pylori positive DNA in all infected patients with full concordance between tissue and stool detection (100%). We found A2143G mutation in 10 (19.2%), A2142G in 4 (7.7%) and A2142C in 5 (9.6%) patients; there was a full agreement between biopsy and fecal samples. A2143G was found in all the four A2142G positive cases and in three out of the five A2142C positive strains. Overall clarithromycin resistance rate in our series was 23%.

CONCLUSIONS

Despite the need of confirmation on large sample, stool RT-PCR analysis could represent a feasible tool to detect H. pylori DNA sequences and antibiotic resistance point mutations. As compared to tissue molecular analysis, this technique is noninvasive, with potential advantages such as improvement of patient compliance, reduction of diagnostic procedure time/cost and improvement of therapeutic outcome.

Treatment of Helicobacter pylori infection: Where are we now?

Gastric cancer and Helicobacter pylori infection remain a burden in many Asian countries. In the face of rising antibiotic resistance, the eradication rate of standard triple therapy is declining in many Asian countries. We reviewed the updated epidemiology of gastric cancer, prevalence of H. pylori infection, and antibiotic resistance in Asia. We also reviewed the strategies to improve the efficacy of H. pylori eradication therapies, including the use of high dose proton pump inhibitor, four drug therapies (including bismuth quadruple, concomitant, and sequential therapy), susceptibility guided therapy, extending the treatment duration to 14 days, and development of effective rescue therapy. Four drug therapies are usually more effective than triple therapy when given in the same duration, except in areas with concomitantly high metronidazole resistance and low clarithromycin resistance. The efficacies of different four drug regimens appeared to be similar. However, trials from different geographic areas showed contradictory results, indicating that the optimal therapy should be decided according to the local prevalence of antibiotic resistance. We proposed a prediction model to calculate the efficacy of different regimens according to the prevalence of antibiotic resistance. More large randomized trials which provide information on the antibiotic resistance are urgently needed to build a more accurate and reliable model. It is hoped that we will be able to decide the optimal regimens by routine surveillance of antibiotic resistance.

Role of concomitant therapy for Helicobacter pylori eradication: A technical note

We read with interest the recent meta-analysis by Lin et al who evaluated the effectiveness of concomitant regimen for Helicobacter pylori (H. pylori) in Chinese regions. They found that 7-d concomitant regimen is undoubtedly superior to 7-d triple therapy (91.2% vs 77.9%, P < 0.0001). However, it is a common belief that a triple therapy lasting 7 d should be definitively removed from the clinical practice for its ineffectiveness. Only its prolongation to 14 d may give satisfactory success rate. Thus, the assessment of an old and outdated treatment versus a more recent and successful one does not seem to bring novel and useful information. Moreover, a 7-d duration has not been ascertained for concomitant regimen, as main guidelines recommend a 10-d schedule for this scheme. Therefore, only studies comparing 10-d concomitant versus 14-d triple seem to be appropriate according to current Guidelines and would clarify which regimen is the most suitable worldwide. Additionally, in this meta-analysis concomitant and sequential therapy showed similar performances, despite it is common opinion that sequential is more prone than concomitant therapy to fail when metronidazole resistance occurs, and China is characterized by high rate of resistance to this antibiotic. None of the included studies evaluated a priori antibiotic resistances, and the lack of this detail hampers the unveiling of this apparent contradiction. In conclusion, the lack of the evaluation of the quality of included trials as well as their high heterogeneity constitute a burdensome limit to draw solid conclusions in this meta-analysis. On the bases of these considerations and the low number of examined trials, we believe that further studies and the knowledge of antibiotic resistances will support with high quality evidence which is the best regimen and its optimal duration.

Ten-day empirical sequential or concomitant therapy is more effective than triple therapy for Helicobacter pylori eradication: A multicenter, prospective study

BACKGROUND

The resistance of Helicobacter pylori to antibiotics has increased the need for new empirical, first-line treatments. However, the efficacy of sequential therapy (ST) and concomitant therapy (CT) compared with triple therapy (TT) has not been adequately evaluated.

AIM

In this study, we evaluated the efficacy of these empirical three regimens.

METHODS

The 517 patients enrolled in the study were prospectively randomized to receive 10 days of TT (n=171), ST (n=170), and CT (n=176) at 5 university-affiliated hospitals from May 2013 to March 2015. The post-treatment H. pylori status was determined using the (13)C-urea breath test.

RESULTS

The baseline characteristics were similar among the three groups. The intention-to-treat eradication rates were 62.6%, 70.6%, and 77.8% in the TT, ST, and CT groups, respectively (p<0.01). The corresponding per-protocol eradication rates were 82.8%, 89.5%, and 94.4%, respectively (p<0.01). There were no significant differences in the compliance, side effects, and follow-up loss rates.

CONCLUSION

A higher eradication rate was achieved with empirical 10-day ST, and CT than with the TT regimen, with similar rates of compliance and treatment side effects.

Characteristics and Risk Factors of Helicobacter pylori Associated Gastritis: A Prospective Cross-Sectional Study in Northeast Thailand

Background and Aim. Risk factors for Helicobacter pylori infection are genetic susceptibility and poor living conditions. This study aimed to investigate the Mdm2 gene, clarithromycin resistance, and possible risk factors for Helicobacter pylori infection. Methods. Risk factors and clinical characteristics were analyzed, including patient demographic data, patient income, personal history, possible source of transmission, patient symptoms, endoscopic findings, patterns of clarithromycin resistance, and patterns of Mdm2 SNIP309. Results. Ingestion of pickled fish (OR = 11.27, 95% CI = 4.31-29.45, p < 0.0001), salt crab (OR = 8.83, 95% CI = 1.99-39.14, p < 0.001), and Papaya salad (OR = 8.73, 95% CI = 4.54-16.79, p < 0.01). The prevalence of clarithromycin resistance was 56% (wild type, A2143/2142A, is 23.8%; mutation, A2143/2142CG, is 35.7%; wild type + mutation is 40.5%). The genetic polymorphisms of Mdm2 SNIP309 were SNIP309 T/T homozygous in 78%, SNIP309 G/T heterozygous in 19%, and SNIP309 G/G homozygous in 3%. Conclusion. Pickled fish, salt crab, and Papaya salad are positive risk factors. There was high prevalence of clarithromycin resistance. The Mdm2 SNIP309 G/G homozygous genotype might be a risk factor for gastric cancer and the fact that it is infrequent in Thailand.