Empirical rescue therapy after Helicobacter pylori treatment failure: a 10-year single-centre study of 500 patients

Third-line and rescue therapy for refractory Helicobacter pylori infection: A systematic review

BACKGROUND

Due to increasing resistance rates of Helicobacter pylori (H. pylori) to different antibiotics, failures in eradication therapies are becoming more frequent. Even though eradication criteria and treatment algorithms for first-line and second-line therapy against H. pylori infection are well-established, there is no clear recommendation for third-line and rescue therapy in refractory H. pylori infection.

AIM

To perform a systematic review evaluating the efficacy and safety of rescue therapies against refractory H. pylori infection.

METHODS

A systematic search of available rescue treatments for refractory H. pylori infection was conducted on the National Library of Medicine’s PubMed search platform based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized or non-randomized clinical trials and observational studies evaluating the effectiveness of H. pylori infection rescue therapies were included.

RESULTS

Twenty-eight studies were included in the analysis of mean eradication rates as rescue therapy, and 21 of these were selected for analysis of mean eradication rate as third-line treatment. For rifabutin-, sitafloxacin-, levofloxacin-, or metronidazole-based triple-therapy as third-line treatment, mean eradication rates of 81.6% and 84.4%, 79.4% and 81.5%, 55.7% and 60.6%, and 62.0% and 63.0% were found in intention-to-treat (ITT) and per-protocol (PP) analysis, respectively. For third-line quadruple therapy, mean eradication rates of 69.2% and 72.1% were found for bismuth quadruple therapy (BQT), 88.9% and 90.9% for bismuth quadruple therapy, three-in-one, Pylera^® (BQT-Pylera), and 61.3% and 64.2% for non-BQT) in ITT and PP analysis, respectively. For rifabutin-, sitafloxacin-, levofloxacin-, or metronidazole-based triple therapy as rescue therapy, mean eradication rates of 75.4% and 78.8%, 79.4 and 81.5%, 55.7% and 60.6%, and 62.0% and 63.0% were found in ITT and PP analysis, respectively. For quadruple therapy as rescue treatment, mean eradication rates of 76.7% and 79.2% for BQT, 84.9% and 87.8% for BQT-Pylera, and 61.3% and 64.2% for non-BQT were found in ITT and PP analysis, respectively. For susceptibility-guided therapy, mean eradication rates as third-line and rescue treatment were 75.0% in ITT and 79.2% in PP analysis.

CONCLUSION

We recommend sitafloxacin-based triple therapy containing vonoprazan in regions with low macrolide resistance profile. In regions with known resistance to macrolides or unavailability of bismuth, rifabutin-based triple therapy is recommended.

Empirical vs. Susceptibility-Guided Treatment of Helicobacter pylori Infection: A Systematic Review and Meta-Analysis

Background

Treating Helicobacter pylori infection according to antibiotic resistance has been frequently recommended. However, information on its real effectiveness is scarce.

Aim

The aim of this study is to perform a meta-analysis comparing empirical vs. susceptibility-guided treatment of H. pylori.

Methods

Selection of studies: Studies comparing empirical versus susceptibility-guided treatment were selected. Search strategy: electronic and manual up to August 2021. Data synthesis: by intention-to-treat (random-effects model).

Results

Overall, 54 studies were included (6,705 patients in the susceptibility-guided group and 7,895 in the empirical group). H. pylori eradication rate was 86 vs. 76%, respectively (RR: 1.12; 95% CI: 1.08-1.17; I 2: 83%). Similar results were found when only RCTs were evaluated (24 studies; RR: 1.16; 95% CI: 1.11-1.22; I 2: 71%) and when susceptibility testing was assessed by culture (RR: 1.12; 95% CI: 1.06-1.18) or PCR (RR: 1.14; 95% CI: 1.05-1.23). For first-line treatments (naïve patients; 30 studies), better efficacy results were obtained with the susceptibility-guided strategy (RR: 1.15; 95% CI: 1.11-1.20; I 2: 79%). However, for empirical first-line quadruple regimens, in particular (both with and without bismuth, excluding the suboptimal triple therapies), not based on CYP2C19 gene polymorphism, no differences in efficacy were found compared with the susceptibility-guided group (RR: 1.04; 95% CI: 0.99-1.09); this lack of difference was confirmed in RCTs (RR: 1.05; 95% CI: 0.99-1.12). For rescue therapies (13 studies, most 2nd-line), similar results were demonstrated for both strategies, including all studies (RR: 1.09; 95% CI: 0.97-1.22; I 2: 82%) and when only RCTs were considered (RR: 1.15; 95% CI: 0.97-1.36).

Conclusion

The benefit of susceptibility-guided treatment over empirical treatment of H. pylori infection could not be demonstrated, either in first-line (if the most updated quadruple regimens are prescribed) or in rescue therapies.

V Spanish Consensus Conference on Helicobacter pylori infection treatment

Helicobacter pylori infection is very common in the Spanish population and represents the main cause of chronic gastritis, peptic ulcer, and gastric cancer. The last iteration of Spanish consensus guidelines on H. pylori infection was conducted in 2016. Recent changes in therapeutic schemes along with increasing supporting evidence were key for developing the V Spanish Consensus Conference (May 2021). Fourteen experts performed a systematic review of the scientific evidence and developed a series of recommendations that were subjected to an anonymous Delphi process of iterative voting. Scientific evidence and the strength of the recommendation were classified using GRADE guidelines. An eradication therapy, when prescribed empirically, is considered acceptable when it reliably achieves, or preferably surpass, 90% cure rates. Currently, only quadruple therapies (with or without bismuth) and generally lasting 14 days, accomplish this goal in first- and second-line therapies. A non-bismuth quadruple concomitant regimen (proton pump inhibitor, clarithromycin, amoxicillin, and metronidazole) or a quadruple bismuth-based combination (proton pump inhibitor, bismuth, tetracycline, and metronidazole), are recommended as first-line regimens. Rescue therapies after eradication failure and management of H. pylori infection in peptic ulcer disease were also reviewed.

Evaluating treatments with rifabutin and amoxicillin for eradication of Helicobacter pylori infection in adults: a systematic review

INTRODUCTION

Helicobacter pylori causes dyspepsia, peptic ulcer, and gastric malignancies. Treatments for Helicobacter pylori are mostly empirical depending on regional antibiotic resistances and the patient's history and less frequently susceptibility guided. Helicobacter pylori has a low resistance to rifabutin and has been proposed as an alternative for third-line treatment and beyond but recently has also gained attention for use as first- and second-line treatment.

AREAS COVERED

In this review, the authors systematically searched medical databases in order to present the current eradication rates for any treatment based on the two antibiotics, rifabutin and amoxicillin with a potent acid inhibitor. They also assessed the safety and tolerance of all the relative regimens.

EXPERT OPINION

Treatment with a rifabutin- and amoxicillin-containing regimen is a valuable option when treating difficult to eradicate Helicobacter pylori infections. Its efficacy is overall 71.4%, and it is not influenced by previous antibiotics, gender, smoking habits, and age. Its results were better when used as a first- or second-line treatment. In third-line therapy and beyond, eradication rates are lower. Adverse effects of all rifabutin regimens occurred in 23% of patients and were mostly mild with bone marrow suppression being very low and reversible.

Rifabutin for the Treatment of Helicobacter Pylori Infection: A Review

Nowadays, apart from having to know first-line Helicobacter pylori eradication regimens well, we must also be prepared to face treatment failures. The aim of this review is to summarize the role of rifabutin in the management of H. pylori infection. Bibliographical searches were performed in PubMed. Data on resistance and efficacy of rifabutin-containing regimens on H. pylori eradication were meta-analyzed. Mean H. pylori rifabutin resistance rate (39 studies, including 9721 patients) was 0.13%; when studies only including patients naïve to H. pylori eradication treatment were considered, this figure was even lower (0.07%). Mean H. pylori eradication rate (by intention-to-treat) with rifabutin-containing regimens (3052 patients) was 73%. Respective cure rates for second-, third-, fourth- and fifth-line therapies, were 79%, 69%, 69% and 72%. Most studies administered rifabutin 300 mg/day, which seemed to be more effective than 150 mg/day. The ideal length of treatment remains unclear, but 10–12-day regimens are generally recommended. Adverse events to rifabutin treatment in H. pylori studies were relatively infrequent (15%), and severe adverse events were exceptional (myelotoxicity was the most significant, although always reversible). In summary, rifabutin-containing therapy represents an encouraging strategy generally restricted, at present, to patients where previous (usually multiple) eradication regimens have failed.

Empirical or susceptibility-guided treatment for Helicobacter pylori infection? A comprehensive review

Although susceptibility-guided therapy is frequently recommended for Helicobacter pylori infection, the evidence available to date supporting this strategy is limited. The aim of the present article is to review the advantages and limitations of the susceptibility-guided and the empirical strategies to treat this infection. We performed a bibliographic search to identify studies investigating H. pylori susceptibility-guided therapy. Culture is not the only way to assess antibiotic resistance, as different polymerase chain reaction-based approaches have been developed as alternative methods. For detecting H. pylori antimicrobial resistance, a molecular approach based on a stool sample might enable more convenient, time-saving methods. Unfortunately, the antimicrobial susceptibility cannot be obtained in all cases. Furthermore, antibiotic susceptibility testing in clinical practice yields useful information only for a few antibiotics: clarithromycin, metronidazole, and quinolones. In addition, susceptibility towards clarithromycin and metronidazole in vitro does not necessarily lead to eradication in vivo. In the case of H. pylori therapy failure, we should not re-administer any of the antibiotics against which H. pylori has probably become resistant. Our updated meta-analysis showed that susceptibility-guided treatment is not better than empirical treatment of H. pylori infection in first-line therapy if the most updated quadruple regimens are empirically prescribed, and similar efficacy results were also demonstrated with the two strategies for second-line therapy. Cumulative H. pylori eradication rate with several successive rescue therapies empirically prescribed reaches almost 100%. Finally, the studies that have evaluated the cost-effectiveness of the susceptibility-guided treatment have achieved contradictory results. In summary, we can conclude that the evidence is too limited to support the generalized use of susceptibility-guided therapy for H. pylori treatment in routine clinical practice, either as first-line or as rescue treatment. Nevertheless, it would be recommended that susceptibility tests are performed routinely, even before prescribing first-line treatment, in specialized centers with an interest in H. pylori management.

Efficacy and safety of a new rifabutin-based triple therapy with vonoprazan for refractory Helicobacter pylori infection: A prospective single-arm study

BACKGROUND

A small proportion of Helicobacter pylori-infected individuals in Japan suffer failure of eradication therapy with third-line regimens containing the potent acid suppressor, vonoprazan, and a quinolone.

OBJECTIVES

This prospective study evaluated the efficacy and safety of rifabutin-based triple therapy with vonoprazan for refractory H pylori infection.

METHODS

Patients who failed H pylori eradication by clarithromycin-based first-line, metronidazole-based second-line, and sitafloxacin-based third-line therapies were recruited. After obtaining informed consent, patients received eradication therapy with vonoprazan (20 mg), amoxicillin (750 mg), and rifabutin (150 mg) twice daily for 10 days. Eradication was confirmed by a negative H pylori stool antigen or urea breath test at least 8 weeks after the end of therapy.

RESULTS

Nineteen patients were included in the study. All of the patients completed the course of medication. Eradication of H pylori was confirmed in all of the patients (19/19; 100%, 95% confidence interval; 83-100%). The most common adverse event was soft stool/diarrhea (4/19, 21%). No severe adverse event was observed.

CONCLUSIONS

Ten-day rifabutin with amoxicillin and vonoprazan triple therapy appears to be effective and safe for refractory H pylori infections. However, considering the recent publications showing high eradication rates with vonoprazan amoxicillin dual therapy, confirmation will require future studies comparing our new therapy with vonoprazan-amoxicillin dual with similar doses and duration and with vonoprazan-rifabutin dual therapy.

Protocol of the European Registry on the management of Helicobacter pylori infection (Hp-EuReg)

INTRODUCTION

Helicobacter pylori selectively infects the human stomach, being the most prevalent chronic infection in the world. H pylori presence causes chronic gastritis in 100% of infected patients and is the major cause of relevant diseases such as atrophic gastritis, peptic ulcer disease, and gastric cancer; it is for this reason that from a public health standpoint, it is considered a high-impact pathogen, responsible of a significant morbidity and mortality. Nowadays, there are consensus and clinical guidelines regarding the infection management at a European level and in most of European countries, but no data have shown the level of implementation of these recommendations. The high costs that this infection carries both socially and to the health system require the continuous and systematic assessment of the diagnostic and treatment strategies, as well as the accessibility to diagnostic methods and most efficient drugs.

AIM

To register the diagnosis, management strategies, and treatment of H pylori-infected adult patients in the Digestive Services outpatient clinics throughout Europe.

METHODS

Noninterventionist prospective multicentre international Registry promoted by the European Helicobacter and Microbiota Study Group. National Coordinators will select recruiting gastroenterologists in their country that will register the H pylori-related routine clinical practice consultations they receive in an electronic case report form (e-CRF) provided by AEG-REDCap. Variables retrieved will include clinical, diagnostic, treatment, eradication confirmation, and outcome data. The database will allow researchers to perform specific subanalyses after approval by the Scientific Committee of the study.

Rifabutin-Based Rescue Therapy for Helicobacter pylori Eradication: A Long-Term Prospective Study in a Large Cohort of Difficult-to-Treat Patients

The most commonly used regimens fail to eradicate Helicobacter pylori (H. pylori) infection in 5⁻10% of patients. Those not cured with treatments based on amoxicillin, clarithromycin, nitroimidazoles, fluoroquinolones, bismuth or tetracycline have no other conventional options thereafter. In this prospective long-term monocentric study, patients who failed to eradicate H. pylori following treatment with all conventional antibiotics were included. All subjects were treated with rifabutin 150 mg, amoxicillin 1 g and a standard dose of proton pump inhibitor, twice daily for 14 days. A negative 13C-urea breath test was used four weeks after treatment completion as an index of H. pylori eradication. Three hundred and two patients were included. Fifty-four percent (164/302) had peptic ulcer disease while 45.7% (138/302) had gastritis or functional dyspepsia. Per-protocol eradication and intention-to-treat eradication were achieved in 72.7% and 71.5%, respectively. A univariate analysis showed that gender, ethnic background, smoking habits and familial history of gastric diseases were not predictive factors of response, while with multiple logistic regression analysis, the ethnic background (Italian) predicted a poor response in the second period of the study (2010⁻2017). In conclusion, this study on a large cohort of very difficult-to-treat patients showed that rifabutin-based rescue therapy is an acceptable and safe strategy after multiple eradication failures with conventional antibiotics.

Cumulative Helicobacter Pylori Eradication Rates by Adopting First- and Second- Line Regimens Proposed by the Maastricht IV Consensus in Obese Patients Undergoing Gastric Bypass Surgery

AIMS AND METHODS

Our aim was to assess, in obese patients undergoing Roux-en-Y gastric bypass (RYGB) surgery, the cumulative Helicobacter pylori (HP) eradication rates by adopting Maastricht IV guidelines in areas of high clarithromycin resistance rates (CLT)-14 days concomitant first-line therapy with proton-pump inhibitor (PPI) bid, CLT 500 mg bid, metronidazole (MTZ) 500 bid, and amoxicillin (AMX) 1000 mg bid and 14 days second-line therapy with PPI bid, AMX 1000 mg bid and levofloxacin (LVF) 500 mg od. Single-center prospective study was over 4 years. Endoscopy and HP assessment (by histology or C13 urea breath test) were performed at baseline and post-treatment HP status was assessed by C13 urea breath test 4-6 weeks after the end of therapy.

RESULTS

Seven hundred seventy-seven consecutive HP-positive patients completed concomitant first-line treatment: 636 (81.9%) female, age 41.1 (± 10.2) years. HP was eradicated in 556 patients-71.56% (95% CI: 68.28-74.62%). In the remaining 221 patients, second-line LVF-based regimens eradicated HP in 121 patients-54.75% (95% CI: 48.16-61.18%). These results give 87.13% (95% CI: 84.58-89.31%) ITT and 89.43% (95% CI: 87.03-91.44%) PP cumulative eradication rates. Eradication rates were not significantly different by gender, age, endoscopy findings, and smoking habits.

CONCLUSIONS

By adopting Maastricht IV consensus quadruple concomitant first-line treatment and second-line LVF-based therapy, high cumulative HP eradication rates are achieved but still leaves around 10.6% of obese patients undergoing RYGB in need of the culture and susceptibility testing prior to third-line treatment.

In vitro evaluation of cross-strain inhibitory effects of IgY polyclonal antibody against H. pylori

The present study aimed to evaluate in vitro cross-strain inhibitory effects of IgY polyclonal antibody on both growth and urease enzyme of four local strains of H. pylori. Leghorn chickens were immunized with whole cells of four different strains of H. pylori, separately. Rising of specific IgY was detected by ELISA. The IgY purified using polyethylene glycol method and the purity was evaluated by SDS-PAGE and Western blotting. Each strain was treated with its own-specific and also other strain-specific IgYs. The strain-specific IgY could inhibit the growth of specific strains by 49-72% and also other different strains of H. pylori by 29-86%. Our findings revealed that strain-specific IgY could inhibit urease activity of its own by 64-72% and other different strains by 49-79%. These findings confirmed strain-specific and also cross-strain inhibitory effects of the IgY polyclonal antibody on both growth and urease activity of H. pylori.

Rifabutin-based 10-day and 14-day triple therapy as a third-line and fourth-line regimen for Helicobacter pylori eradication: A pilot study

BACKGROUND AND AIM

This prospective randomized study was designed to assess the efficacy of 10-day and 14-day rifabutin-based triple therapy as a third- or fourth-line rescue therapy.

METHODS

Patients who failed first- and second-line eradication therapy were enrolled. H. pylori was isolated from gastric biopsy specimens and the rpoB mutation status, a factor of resistance to rifamycins, and minimum inhibitory concentrations (MICs) of rifabutin and amoxicillin were determined. Enrolled patients were randomly assigned to receive 10-day or 14-day eradication therapy with esomeprazole (20 mg, 4 times a day (q.i.d.)), amoxicillin (500 mg, q.i.d.), and rifabutin (300 mg, once a day (q.d.s.)). Poor compliance was defined as intake of <80% of study drugs. Successful H. pylori eradication was confirmed using a [13C] urea breath test or a stool antigen test, 12 weeks after the end of therapy.

RESULTS

Twelve patients were assigned to the 10-day group, and 17, to the 14-day group. Intention-to-treat and per-protocol analyses of eradication rates were 83.3% and 81.8% for the 10-day group and 94.1% and 91.7% for the 14-day group, respectively. All patients with rpoB mutation-positive strains (n = 3) showed successful eradication, irrespective of the regimen received. Therapy was stopped due to adverse events in 8.3% and 29.3% of patients in the 10-day and 14-day groups, respectively.

CONCLUSION

Both the 10-day and 14-day therapies were effective as rescue regimens. In particular, the 14-day therapy resulted in successful eradication in over 90% of patients, but the 10-day treatment may be enough to obtain a successful eradication rate, considering the tolerability of therapy.

Systematic review and meta-analysis: susceptibility-guided versus empirical antibiotic treatment for Helicobacter pylori infection

BACKGROUND

The cure rate of standard triple therapy for Helicobacter pylori infection is unacceptably low. Susceptibility-guided therapies (SGTs) have been proposed as an alternative to standard empirical treatments. The aim of this study was to perform a systematic review and meta-analysis evaluating the efficacy of SGTs.

METHODS

A systematic search was performed in multiple databases. Randomized controlled trials comparing cure rates of SGTs versus those of empirical therapy were selected and analysed separately for first- and second-line treatments. A meta-analysis was performed using risk ratio (RR) and number needed to treat (NNT) to measure the effect.

RESULTS

Twelve studies were included in the meta-analysis. In first-line treatment, SGT was more efficacious than empirical 7-10 day triple therapy (RR 1.16, 95% CI 1.10-1.23, I (2) = 33%; NNT = 8). Most studies used a 7-10 day triple therapy and randomized the patients after endoscopy and/or culture, thus precluding the comparison of SGT versus non-invasive testing and empirical treatment in clinical practice. For second-line therapy, only four studies were found. Results were highly heterogeneous and no significant differences were found (RR 1.11, 95% CI 0.82-1.51, I (2) = 87%).

CONCLUSIONS

Once endoscopy and culture have been performed, SGT is superior to empirical 7 or 10 day triple therapy for first-line treatment. Further studies are needed to evaluate the effectiveness of SGT in clinical practice, especially when compared with currently recommended first-line quadruple therapies.

Rescue Therapy with a Proton Pump Inhibitor Plus Amoxicillin and Rifabutin for Helicobacter pylori Infection: A Systematic Review and Meta-Analysis

Background. To conduct a systematic review and meta-analysis of clinical trials for eradication of Helicobacter pylori (H. pylori) that included a treatment arm with a proton pump inhibitor, rifabutin, and amoxicillin. Materials and Methods. We selected clinical trials that examined the efficacy of H. pylori eradication therapies and included a study arm using the test regimen from major medical literature databases and abstracts from major gastroenterology meetings. We also did subgroup and sensitivity analyses. Results. Twenty-one studies were included in systematic review. The total eradication rates of the test regimen were 70.4% by intent-to-treat (ITT) and 72.0% by per-protocol (PP) analyses. The pooled odds ratio (OR) was 0.55 using fixed effects model (P = 0.283) for the test regimen versus other triple regimens. The total eradication rates were 68.4% for the test regimen and 81.9% in the control group by ITT, while the OR was 1.08 using random effects model (P = 0.019). The pooled eradication rate was 66.4% for the test regimen and 67.4% for the control group by ITT. The total adverse effects incidence were 25.1% for the test regimen. Conclusions. The test regimen for H. pylori rescue therapy may be not superior to control regimens in efficacy.

Beyond Maastricht IV: are standard empiric triple therapies for Helicobacter pylori still useful in a South-European country?

Background

Empiric triple treatments for Helicobacter pylori (H. pylori) are increasingly unsuccessful. We evaluated factors associated with failure of these treatments in the central region of Portugal.

Methods

This single-center, prospective study included 154 patients with positive ¹³C-urea breath test (UBT). Patients with no previous H. pylori treatments (Group A, n = 103) received pantoprazole 40 mg 2×/day, amoxicillin 1000 mg 12/12 h and clarithromycin (CLARI) 500 mg 12/12 h, for 14 days. Patients with previous failed treatments (Group B, n = 51) and no history of levofloxacin (LVX) consumption were prescribed pantoprazole 40 mg 2×/day, amoxicillin 1000 mg 12/12 h and LVX 250 mg 12/12 h, for 10 days. H. pylori eradication was assessed by UBT 6–10 weeks after treatment. Compliance and adverse events were assessed by verbal and written questionnaires. Risk factors for eradication failure were determined by multivariate analysis.

Results

Intention-to-treat and per-protocol eradication rates were Group A: 68.9% (95% CI: 59.4–77.1%) and 68.8% (95% CI: 58.9–77.2%); Group B: 52.9% (95% CI: 39.5–66%) and 55.1% (95% CI: 41.3–68.2%), with 43.7% of Group A and 31.4% of Group B reporting adverse events. Main risk factors for failure were H. pylori resistance to CLARI and LVX in Groups A and B, respectively. Another independent risk factor in Group A was history of frequent infections (OR = 4.24; 95% CI 1.04–17.24). For patients with no H. pylori resistance to CLARI, a history of frequent infections (OR = 4.76; 95% CI 1.24–18.27) and active tobacco consumption (OR = 5.25; 95% CI 1.22–22.69) were also associated with eradication failure.

Conclusions

Empiric first and second-line triple treatments have unacceptable eradication rates in the central region of Portugal and cannot be used, according to Maastricht recommendations. Even for cases with no H. pylori resistance to the used antibiotics, results were unacceptable and, at least for CLARI, are influenced by history of frequent infections and tobacco consumption.

Helicobacter pylori eradication in West Asia: A review

The efficacy of first- and second-line Helicobacter pylori (H. pylori) eradication regimens varies considerably in West Asian countries, mainly due to the variable prevalence of resistant organisms. However, no review article has yet evaluated and compared the efficacy of different regimens among different countries of this region. Therefore, we conducted a review to select the best options and provide recommendations for H. pylori treatment in this geographic region. A search through PubMed was carried out to obtain relevant randomized clinical trials published in English language up to June 2013. According to the results, among different therapeutic regimens used as the first-line protocols, 10-d Bismuth-Furazolidone/Metronidazole quadruple therapy, 14-d Clarithromycin-containing hybrid therapy and 14-d quadruple therapy including a proton pump inhibitor + Bismuth + Tetracycline (500 mg QID) + Metronidazole (500 mg TDS) seemed to be appropriate options. Among second-line therapeutic regimens, Bismuth-based quadruple therapies containing Tetracycline and Furazolidone/Metronidazole, triple therapy containing Amoxicillin and Gatifloxacin and Quadruple therapy including Bismuth + Azithromycin and Ofloxacin seemed to be effective options. Third-line therapies were not evaluated in West Asia; most guidelines, however, recommend choosing optimal eradication regimen according to the pattern of antibiotic susceptibility of H. pylori. Although we limited our investigation to H. pylori eradication regimens in West Asia, the clinical significance of the results goes beyond the countries situated in this geographic region. In fact, the results are transferrable to any region as long as the patterns of resistance are the same.

Practical treatment of Helicobacter pylori: a balanced view in changing times

Eradication rates of first-line triple therapy for Helicobacter pylori infection have fallen in the recent years. The main reasons for treatment failure are poor compliance due to complicated treatment regimens and the emergence of antibiotic-resistant strains of H. pylori. Treatment failure is a cause for concern with regard to the complications of H. pylori infection, which include gastric and peptic ulcers, gastric cancer and mucosa-associated lymphoid tissue lymphoma. This review describes considerations for optimizing standard first-line triple therapy, as well as alternatives to the standard first-line treatment, such as bismuth quadruple therapy, sequential therapy, concomitant therapy and hybrid therapy. Studies using levofloxacin-based and rifabutin-based regimens for the treatment of multiresistant infections have also been reviewed. The current most up-to-date systematic reviews and meta-analyses comparing the efficacy of these treatments have been discussed, in light of the recent antimicrobial susceptibility testing data, regional antibiotic resistance rates and the Maastricht IV guidelines on the management of H. pylori infection.

Optimal treatment strategy for Helicobacter pylori: Era of antibiotic resistance

Standard triple therapy, consisting of a proton pump inhibitor, plus amoxicillin and clarithromycin, has been the most commonly used first-line treatment regimen for Helicobacter pylori (H. pylori) eradication for many years worldwide. However, as a result of increased resistance to antibiotics, H. pylori eradication rates with use of standard triple therapy have been declining and recently reached < 80% in many countries. Several new strategies to enhance the eradication rate of H. pylori have been studied. Currently, among the alternative first-line eradication regimens, concomitant and hybrid regimens have shown excellent results and could be the optimal treatment option. Although clinical usefulness of rescue therapy for patients in whom eradication of H. pylori with non-bismuth quadruple regimen has failed is unclear, levofloxacin-based quadruple therapy has shown promise as a rescue treatment. The choice of third-line therapy depends on factors such as the local pattern of antibiotic resistance, drug availability, and previous treatment. We hope that a simple method for detection of antibiotic susceptibility using polymerase chain reaction would be a possible alternative to administration of “tailored treatment” in the era of increasing prevalence of antimicrobial resistance.

In vitro bacteriostatic activity of IgY against recombinant Helicobacter pylori FlaA protein

AIM: To evaluate the in vitro antibacterial activity of anti-Helicobacter pylori (H. pylori) FlaA IgY.

METHODS: Recombinant H. pylori FlaA was prepared by prokaryotic expression and used to immunize hens. Anti-FlaA IgY was purified and IgY titer was determined by ELISA. The antibody was then tested to check if there was any cross-reaction with the common intestinal flora like Lacticacid bacteria, Bifidobacterium and Escherichia coli. The antibacterial activity of different concentrations of anti-H. pylori FlaA IgY (0.1, 1 and 5 mg/mL) was finally determined.

RESULTS: The concentration of purified FlaA protein was 2.97 mg/mL, and the titer of anti-FlaA IgY was 1:12800 three weeks after immunization. Anti-FlaA IgY did not react with the common intestinal flora, but reacted well with H. pylori and FlaA protein. In vitro results showed that there were significant differences (P < 0.01) in the H. pylori concentrations between the control group and the groups treated with 0.1, 1, or 5 mg/mL FlaA IgY, indicating that FlaA IgY of various concentrations could inhibit the growth of H. pylori in a certain degree. The antibacterial activity of 0.1 mg/mL FlaA IgY was mainly present between 1 and 6 h, and was mostly lost after 6 h. The growth of H. pylori treated with 1 mg/mL FlaA IgY was relatively slow, and the bacterial concentration of the group treated with 5 mg/mL FlaA IgY did not alter significantly between 1 and 24 h. After 108 CFU/mL H. pylori was treated with three different doses (0.1, 1, 5 mg/mL) of FlaA IgY for 24 h, a significant difference in bacterial concentration was observed between the low dose group and the other two groups (P < 0.01). Anti-FlaA IgY at 5 mg/mL could completely inhibit the growth of H. pylori.

CONCLUSION: High-titer anti-FlaA IgY can specifically react with H. pylori, and has no cross-reaction with the common intestinal flora. Anti-FlaA IgY at 5 mg/mL has a strong inhibitory effect on the growth of H. pylori.

Clinical management of Helicobacter pylori: the Latin American perspective

In most South American countries, Helicobacter pylori infection prevalence is high, affecting over 70% in populations with precarious living conditions. It is worth pointing out that there is initial evidence of a decline in prevalence of H. pylori infection at least in some more privileged fragments of the population. It is estimated that gastric cancer, the main clinical sequela of H. pylori infection, has an average incidence rate of 12.4 cases per 100,000 inhabitants (8.4 cases per 100,000 inhabitants for women and 17.3 cases per 100,000 for men) in the region. Classical triple therapy [proton pump inhibitor (PPI), amoxicillin and clarithromycin] is still the most used regimen with eradication rates around 80%. The rates of resistance to clarithromycin range from 2 to 24%. Recurrence rates of the infection are described as 2.9% in Argentina, 4.2% in Chile, 2-7% in Brazil, and 11.5% in a trial involving 7 Latin American countries. After failure of clarithromycin-containing regimens, second- and third-line therapies using PPI, amoxicillin and levofloxacin and quadruple therapy with PPI, colloidal bismuth subcitrate, tetracycline hydrochloride and metronidazole are recommended. Due to the high rates of primary resistance to metronidazole in the Latin American countries, use of the quadruple therapy, replacing metronidazole for furazolidone, is a frequent option. Rescue triple therapy regimens using furazolidone in association with levofloxacin and PPI have also been used. Most recommended rescue therapies reach eradication rates close to 80%.

Triple therapy with high-dose proton-pump inhibitor, amoxicillin, and doxycycline is useless for Helicobacter pylori eradication: a proof-of-concept study

INTRODUCTION

Helicobacter pylori resistance to antibiotics is steadily increasing and multidrug-resistant strains are common and difficult to eliminate, mainly in countries where bismuth, tetracycline, furazolidone, and rifabutin are unavailable.

AIM

To evaluate the efficacy and safety of a triple therapy with proton-pump inhibitor (PPI), amoxicillin, and doxycycline in patients with multidrug-resistant H. pylori.

PATIENTS AND METHODS

This prospective study involved 16 patients (13 females; mean age - 50 ± 11.3 years) infected by H. pylori with known resistance to clarithromycin, metronidazole, and levofloxacin, but susceptibility to amoxicillin and tetracycline. All patients were previously submitted to upper endoscopy with gastric biopsies for H. pylori culture and susceptibility testing by Etest. Mutations in 23S rRNA and gyrA genes were determined by real-time PCR. A 10-day eradication regimen with PPI (double-standard dose b.i.d.), amoxicillin (1000 mg b.i.d.), and doxycycline (100 mg b.i.d.) was prescribed after pretreatment with PPI during 3 days. Eradication success was assessed by (13) C-urea breath test 6-10 weeks after treatment. Compliance and adverse events were determined through phone contact immediately after treatment and specific written questionnaires.

RESULTS

Only one patient did not complete treatment due to adverse events. Another four patients experienced mild side effects not affecting compliance. The control (13) C-urea breath test was positive in all patients. Per-protocol and intention-to-treat eradication rates were 0%.

CONCLUSIONS

Although safe, a triple-therapy protocol with high-dose PPI, amoxicillin, and doxycycline is useless for multidrug-resistant H. pylori eradication.

Helicobacter pylori: evidence-based review with a focus on immigrant populations

Helicobacter pylori has been causally linked to a number of diseases, including peptic ulcer disease, gastric adenocarcinoma, mucosa-associated lymphoid tissue lymphoma, and dyspepsia. It is the most prevalent bacterial pathogen in humans, and while the overall prevalence in the United States is about 30 %, the distribution is heterogeneous amongst different ethnic groups. Recent immigrants from high prevalence areas such as Korea, Japan, and China bear an increased burden of its disease and complications. There is clear evidence that treatment of H. pylori resolves peptic ulcer disease, and increasing evidence for protection against development of gastric adenocarcinoma. However, H. pylori treatment failure is common and alternative regimens may be necessary. The following case-based review will highlight these issues, including the epidemiology of H. pylori in the immigrant population, an approach to dyspepsia, and the role of H. pylori in gastric adenocarcinoma.

Third-line rescue therapy with bismuth-containing quadruple regimen after failure of two treatments (with clarithromycin and levofloxacin) for H. pylori infection

BACKGROUND

Helicobacter pylori eradication therapy with a proton pump inhibitor (PPI), clarithromycin, and amoxicillin fails in >20 % of cases. A rescue therapy with PPI-amoxicillin-levofloxacin still fails in >20 % of patients.

AIM

To evaluate the efficacy and tolerability of a bismuth-containing quadruple regimen in patients with two consecutive eradication failures.

METHODS

Prospective multicenter study of patients in whom 1st treatment with PPI-clarithromycin-amoxicillin and 2nd with PPI-amoxicillin-levofloxacin had failed. A 3rd eradication regimen with a 7- to 14-day PPI (standard dose b.i.d.), bismuth subcitrate (120 mg q.i.d. or 240 mg b.i.d.), tetracycline (from 250 mg t.i.d. to 500 mg q.i.d.) and metronidazole (from 250 mg t.i.d. to 500 mg q.i.d.). Eradication was confirmed by (13)C-urea-breath-test 4-8 weeks after therapy. Compliance was determined through questioning and recovery of empty medication envelopes. Adverse effects were evaluated by means of a questionnaire.

RESULTS

Two hundred patients (mean age 50 years, 55 % females, 20 % peptic ulcer/80 % uninvestigated-functional dyspepsia) were initially included, and two were lost to follow-up. In all, 97 % of patients complied with the protocol. Per-protocol and intention-to-treat eradication rates were 67 % (95 % CI 60-74 %) and 65 % (58-72 %). Adverse effects were reported in 22 % of patients, the most common being nausea (12 %), abdominal pain (11 %), metallic taste (8.5 %), and diarrhea (8 %), none of them severe.

CONCLUSION

A bismuth-containing quadruple regimen is an acceptable third-line strategy and a safe alternative after two previous H. pylori eradication failures with standard clarithromycin- and levofloxacin-containing triple therapies.

Efficacy of two levofloxacin-containing second-line therapies for Helicobacter pylori: a pilot study

BACKGROUND

An ideal second-line therapeutic regimen for the treatment of patients who do not respond to standard triple therapy is currently being investigated. In this study, we aimed to investigate the efficacy of two levofloxacin-containing second-line therapies for Helicobacter pylori (H. pylori).

MATERIALS AND METHODS

One hundred and forty eight consecutive H. pylori -positive patients who did not respond to the standard triple therapy (77 female, 71 male) were enrolled in the study. The patients were randomized consecutively to two-second-line therapy groups; 73 to the levofloxacin-containing sequential (LCS) and 75 to the levofloxacin-containing quadruple (LCQ) therapy group. The LCS therapy group received pantoprazole 40 mg and amoxicillin 1,000 mg twice daily for 5 days followed by pantoprazole 40 mg twice daily and metronidazole 500 mg three times daily and levofloxacin 500 mg one time daily for 7 days. The LCQ therapy group received pantoprazole 40 mg twice daily, tetracycline 500 mg four times daily, bismuth subcitrate 300 mg four times daily and levofloxacin 500 mg one time daily for 10 days. H. pylori eradication was confirmed by stool antigen testing at least 6 weeks after cessation of therapy. Side-effects and compliance were assessed by a questionnaire.

RESULTS

Intention-to-treat cure rates were: 82.2% (95%CI; 73-91) and 90.6% (95%CI; 79-95) in the LCS and LCQ therapy, respectively. Per protocol cure rates were: 85.7% (95%CI; 75-92) and 93.1% (95%CI; 85-98) in the LCS and LCQ therapy, respectively. No statistically significant difference was found between two groups (p = .1). No differences in compliance or adverse effects were demonstrated between two groups.

CONCLUSIONS

This prospective trial demonstrates that both levofloxacin-containing sequential therapy and levofloxacin-containing quadruple therapy regimens have higher H. pylori eradication rates and are well tolerated. The levofloxacin-containing quadruple therapy is likely the best treatment option for a second-line therapy, at least in the Turkish population.

Levofloxacin, Metronidazole, and Lansoprazole Triple Therapy Compared to Quadruple Therapy as a Second-Line Treatment of Helicobacter pylori Infection in Korea

Background/Aims

Several rescue therapies have been recommended to eradicate Helicobacter pylori infection in patients with a failure of first-line eradication therapy, but they still fail in more than 20% of cases. The aim of this study was to evaluate the efficacy and safety of levofloxacin, metronidazole, and lansoprazole (LML) triple therapy relative to quadruple therapy as a second-line treatment.

Methods

In total, 113 patients who failed first-line triple therapy for H. pylori infection were randomly assigned to two groups: LML for 7 days and tetracycline, bismuth subcitrate, metronidazole and lansoprazole (quadruple) for 7 days.

Results

According to intention-to-treat analysis, the infection was eradicated in 38 of 56 patients (67.9%) in the LML group and 48 of 57 (84.2%) in the quadruple group (p=0.042). Per-protocol analysis showed successful eradication in 38 of 52 patients (73.1%) from the LML group and 48 of 52 (92.3%) from the quadruple group (p=0.010). There were no significant differences in the adverse effects in either treatment group.

Conclusions

LML therapy is less effective than quadruple therapy as a second-line treatment for H. pylori infection. Therefore, quadruple therapy should be considered as the primary second-line strategy for patients experiencing a failure of first-line H. pylori therapy in Korea.

Treatment for H. pylori infection: new challenges with antimicrobial resistance

The treatment of Helicobacter pylori infection is in a state of flux as traditional therapies fail and new therapies do not achieve the 90% eradication rates desired by clinicians. Triple therapy, which has been the mainstay of treatment in many countries over the last decade, now has suboptimal results in many parts of the world. A number of new treatments have been described with variable success in different parts of the world. In this article, the fundamentals of treatment for H. pylori treatment are reviewed and new treatment algorithms are proposed for regions of the world where triple therapy is failing. Sequential therapy and quadruple therapy (either bismuth-based or non-bismuth-based) are the best current options to replace initial treatment with triple therapy. When initial treatment fails, salvage treatments using rifabutin and levofloxacin are the best options. With knowledge of local resistance patterns and with meticulous confirmation of eradication with retreatment, most H. pylori infections can be successfully eradicated.

3rd Brazilian Consensus on Helicobacter pylori

Signicant progress has been obtained since the Second Brazilian Consensus Conference on Helicobacter pylori Infection held in 2004, in São Paulo, SP, Brazil, and justify a third meeting to establish updated guidelines on the current management of H. pylori infection. The Third Brazilian Consensus Conference on H pylori Infection was organized by the Brazilian Nucleus for the Study of Helicobacter, a Department of the Brazilian Federation of Gastroenterology and took place on April 12-15, 2011, in Bento Gonçalves, RS, Brazil. Thirty-one delegates coming from the five Brazilian regions and one international guest, including gastroenterologists, pathologists, epidemiologists, and pediatricians undertook the meeting. The participants were allocated in one of the five main topics of the meeting: H pylori, functional dyspepsia and diagnosis; H pylori and gastric cancer; H pylori and other associated disorders; H pylori treatment and retreatment; and, epidemiology of H pylori infection in Brazil. The results of each subgroup were submitted to a final consensus voting to all participants. Relevant data were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded. Seventy per cent and more votes were considered as acceptance for the final statement. This article presents the main recommendations and conclusions to guide Brazilian doctors involved in the management of H pylori infection.

A review of rescue regimens after clarithromycin-containing triple therapy failure (for Helicobacter pylori eradication)

INTRODUCTION

Helicobacter pylori infection is generally treated with therapies that include a proton pump inhibitor (PPI) and, at least, two antibiotics being clarithromycin one of the most used. Antibiotic resistance, mainly to clarithromycin, seems to be increasing in many geographical areas, and this factor is considered a main cause leading to a treatment failure when the later therapies contain this antibiotic again. As clarithromycin is a key antibiotic in the eradication of H. pylori, the election of the rescue treatment is a matter of debate.

AREAS COVERED

The aim of this study is to systematically review the efficacy of the second-line rescue therapies after the failure of a first-line clarithromycin-containing regimen, and to link this information with the previous first-line treatment. Also, authors performed meta-analyses and inverse variance analyses with studies that met the inclusion criteria: first-line treatment must specify type and dosage; diagnosis and eradication confirmation must be performed by generally accepted tests; and second-line treatment must not be assigned depending on the antibiotic susceptibility or resistance.

EXPERT OPINION

In a routine clinical practice setting, the most adequate second-line treatment consists in a 10-day regimen of levofloxacin- amoxicillin-PPI given twice daily, unless regional or new data show high quinolone resistance. Other good options are the bismuth quadruple regimen and a metronidazole-amoxicillin-PPI therapy.

Second-line therapy with levofloxacin after failure of treatment to eradicate helicobacter pylori infection: time trends in a Spanish Multicenter Study of 1000 patients

BACKGROUND

Second-line bismuth-containing quadruple therapy is complex and frequently induces adverse effects. A triple rescue regimen containing levofloxacin is a potential alternative; however, resistance to quinolones is rapidly increasing.

AIM

To evaluate the efficacy and tolerability of a second-line triple-regimen-containing levofloxacin in patients whose Helicobacter pylori eradication treatment failed and to assess whether the efficacy of the regimen decreases with time.

DESIGN

Prospective multicenter study.

PATIENTS

In whom treatment with a regimen comprising a proton-pump inhibitor, clarithromycin, and amoxicillin had failed.

INTERVENTION

Levofloxacin (500 mg bid), amoxicillin (1 g bid), and omeprazole (20 mg bid) for 10 days.

OUTCOME

Eradication was confirmed using the C-urea breath test 4 to 8 weeks after therapy. Compliance/tolerance: Compliance was determined through questioning and recovery of empty medication envelopes. Incidence of adverse effects was evaluated by means of a questionnaire.

RESULTS

The study sample comprised 1000 consecutive patients (mean age, 49 ± 15 y, 42% men, 33% peptic ulcer) of whom 97% took all medications correctly. Per-protocol and intention-to-treat eradication rates were 75.1% (95% confidence interval, 72%-78%) and 73.8% (95% confidence interval, 71%-77%). Efficacy (intention-to-treat) was 76% in the year 2006, 68% in 2007, 70% in 2008, 76% in 2009, 74% in 2010, and 81% in 2011. In the multivariate analysis, none of the studied variables (including diagnosis and year of treatment) were associated with success of eradication. Adverse effects were reported in 20% of patients, most commonly nausea (7.9%), metallic taste (3.9%), myalgia (3.1%), and abdominal pain (2.9%).

CONCLUSIONS

Ten-day levofloxacin-containing therapy is an encouraging second-line strategy, providing a safe and simple alternative to quadruple therapy in patients whose previous standard triple therapy has failed. The efficacy of this regimen remains stable with time.

[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]

The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources. This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).

[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]

The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources.This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).

Different Antibiotic No Culture Eradicating (DANCE) strategy: an easy way to manage H. pylori eradication

Treatment of Helicobacter pylori infection is becoming a very relevant problem especially in industrialized Countries. Although different therapeutic regimens are currently available, treatment failure remains a growing problem in daily medical practice. Several factors could play a role in the eradication failure, but the most relevant are antibiotic resistance and patient's compliance. While Helicobacter pylori resistance to amoxicillin is rare, clarithromycin and metronidazole resistance varies significantly from close to zero up to 25%. However, metronidazole in vitro resistance exhibits a lower impact on eradication success because resistance in vitro does not reflect that in vivo. Specific guidelines have then been published, mostly based on antibiotic resistance among different geographic areas. Basically, first-line and second-line regimens have been well defined; concerning third-line treatment Maastricht III guidelines suggest to adopt a culture-based approach. Culture is, however, expensive, invasive and available only in few specialized centres. An alternative approach may be to use an empirical strategy, based on the avoidance of repeating similar eradicating schemes in the same patients during the course of different eradicating regimens. For this approach we propose the acronym DANCE (Different Antibiotic No Culture Eradicating) strategy. When correctly applied, this approach showed to reach successful eradication in up to 99.5% of Helicobacter pylori-positive patients.

Levofloxacin/amoxicillin-based schemes vs quadruple therapy for Helicobacter pylori eradication in second-line

Worldwide prevalence of Helicobacter pylori (H. pylori) infection is approximately 50%, with the highest being in developing countries. We compared cure rates and tolerability (SE) of second-line anti-H. pylori levofloxacin/amoxicillin (LA)-based triple regimens vs standard quadruple therapy (QT). An English language literature search was performed up to October 2010. A meta-analysis was performed including randomized clinical trials comparing 7- or 10-d LA with 7-d QT. In total, 10 articles and four abstracts were identified. Overall eradication rate in LA was 76.5% (95% CI: 64.4%-97.6%). When only 7-d regimens were included, cure rate was 70.6% (95% CI: 40.2%-99.1%), whereas for 10-d combinations, cure rate was significantly higher (88.7%; 95% CI: 56.1%-109.9%; P < 0.05). Main eradication rate for QT was 67.4% (95% CI: 49.7%-67.9%). The 7-d LA and QT showed comparable efficacy [odds ratio (OR): 1.09; 95% CI: 0.63-1.87], whereas the 10-d LA regimen was significantly more effective than QT (OR: 5.05; 95% CI: 2.74-9.31; P < 0.001; I² = 75%). No differences were reported in QT eradication rates among Asian and European studies, whereas LA regimens were more effective in European populations (78.3% vs 67.7%; P = 0.05). Incidence of SE was lower in LA therapy than QT (OR: 0.39; 95% CI: 0.18-0.85; P = 0.02). A higher rate of side effects was reported in Asian patients who received QT. Our findings support the use of 10-d LA as a simple second-line treatment for H. pylori eradication with an excellent eradication rate and tolerability. The optimal second-line alternative scheme might differ among countries depending on quinolone resistance.

Efficacy of a therapeutic strategy for eradication of Helicobacter pylori infection

AIM: To determine the efficacy of our therapeutic strategy for Helicobacter pylori (H. pylori) eradication and to identify predictive factors for successful eradication.

METHODS: From April 2006 to June 2010, we retrospectively assessed 2428 consecutive patients (1025 men, 1403 women; mean age 55 years, age range 18-92 years) with gastric histology positive for H. pylori infection referred to our unit for 13-C urea breath test (UBT), after first-line therapy with proton pump inhibitor (PPI) b.i.d. + amoxicillin 1 g b.i.d. + clarithromycin 500 mg b.i.d. for 7 d. Patients who were still positive to UBT were recommended a second-line therapy (PPI b.i.d. + amoxicillin 1 g b.i.d. + tinidazole 500 mg b.i.d. for 14 d). Third choice treatment was empirical with PPI b.i.d. + amoxicillin 1 g b.i.d. + levofloxacin 250 mg b.i.d. for 14 d.

RESULTS: Out of 614 patients, still H. pylori-positive after first-line therapy, only 326 and 19 patients respectively rechecked their H. pylori status by UBT after the suggested second and third-line regimens. “Per protocol” eradication rates for first, second and third-line therapy were 74.7% (95% CI: 72.7%-76.4%), 85.3% (95% CI: 81.1%-89.1%) and 89.5% (95% CI: 74.9%-103%) respectively. The overall percentage of patients with H. pylori eradicated after two treatments was 97.8% (95% CI: 97.1%-98.4%), vs 99.9% (95% CI: 99.8%-100%) after three treatments. The study found that eradication therapy was most effective in patients with ulcer disease (P < 0.05, P = 0.028), especially in those with duodenal ulcer. Smoking habits did not significantly affect the eradication rate.

CONCLUSION: First-line therapy with amoxicillin and clarithromycin produces an H. pylori eradication rate comparable or superior to other studies and second-line treatment can still be triple therapy with amoxicillin and tinidazole.

Long-term follow-up of 1,000 patients cured of Helicobacter pylori infection following an episode of peptic ulcer bleeding

OBJECTIVES

To evaluate the effect of Helicobacter pylori (H. pylori) eradication on ulcer bleeding recurrence in a prospective, long-term study including 1,000 patients.

METHODS

Patients with peptic ulcer bleeding were prospectively included. Prior non-steroidal anti-inflammatory drug (NSAID) use was not considered exclusion criteria. H. pylori infection was confirmed by rapid urease test, histology, or (13)C-urea breath test. Several eradication therapies were used. Subsequently, ranitidine 150 mg o.d. was administered until eradication was confirmed by (13)C-urea breath test 8 weeks after completing therapy. Patients with therapy failure received a second, third, or fourth course of eradication therapy. Patients with eradication success did not receive maintenance anti-ulcer therapy and were controlled yearly with a repeat breath test. NSAID use was not permitted during follow-up.

RESULTS

Thousand patients were followed up for at least 12 months, with a total of 3,253 patient-years of follow-up. Mean age 56 years, 75% males, 41% previous NSAID users. In all, 69% had duodenal ulcer, 27% gastric ulcer, and 4% pyloric ulcer. Recurrence of bleeding was demonstrated in three patients at 1 year (which occurred after NSAID use in two cases, and after H. pylori reinfection in another one), and in two more patients at 2 years (one after NSAID use and another after H. pylori reinfection). The cumulative incidence of rebleeding was 0.5% (95% confidence interval, 0.16-1.16%), and the incidence rate of rebleeding was 0.15% (0.05-0.36%) per patient-year of follow up.

CONCLUSION

Peptic ulcer rebleeding virtually does not occur in patients with complicated ulcers after H. pylori eradication. Maintenance anti-ulcer (antisecretory) therapy is not necessary if eradication is achieved. However, NSAID intake or H. pylori reinfection may exceptionally cause rebleeding in H. pylori-eradicated patients.

Helicobacter pylori infection: sequential therapy followed by levofloxacin-containing triple therapy provides a good cumulative eradication rate

BACKGROUND

In the eradication of H. pylori infection, even today, the main international guidelines recommend the triple therapy as first-line regimen, although its effectiveness is clearly decreasing. As second-line treatment, the bismuth-containing quadruple therapy is the most used regimen, although several other therapies are studied. The Italian guidelines recommend, alternatively, sequential therapy or triple therapy as first-line treatment and levofloxacin-containing triple therapy as second-line regimen. We wanted to assess the overall eradication rate of Helicobacter pylori infection in two therapeutic rounds following the Italian guidelines in clinical practice.

MATERIALS AND METHODS

We treated 231 consecutive Helicobacter pylori-positive patients by sequential therapy and we verified the eradication 8-10 weeks after treatment by stool antigen test. Patients positive for stool antigen test received levofloxacin-containing triple therapy, as second-line therapy, according to Italian Guidelines and they were again submitted to the fecal test 8-10 weeks after the end of treatment.

RESULTS

In the first-line regimen, we obtained an eradication rate of 92.6%, in the second-line of 75.0% and as cumulative result we achieved a 97.8% of eradication, in per-protocol analysis.

CONCLUSIONS

Sequential therapy as first-line and levofloxacin-containing triple therapy as second-line represent a good combination to eradicate Helicobacter pylori infection in only two rounds.

Helicobacter pylori Eradication Therapies in the Era of Increasing Antibiotic Resistance: A Paradigm Shift to Improved Efficacy

With the rising prevalence of antimicrobial resistance, the eradication rates of Helicobacter pylori (H. pylori) with standard treatments are decreasing to unacceptable levels (i.e., ≤80%) in most countries. After these disappointing results, several authorities have proposed that infection with H. pylori should be approached and treated as any other bacterial infectious disease. This implicates that clinicians should prescribe empirical treatments yielding a per protocol eradication of at least 90%. In recent years several treatments producing ≥90% cure rates have been proposed including sequential therapy, concomitant quadruple therapy, hybrid (dual-concomitant) therapy, and bismuth-containing quadruple therapy. These treatments are likely to represent the recommended first-line treatments in the near future. In the present paper, we are considering a series of critical issues regarding currently available means and approaches for the management of H. pylori infection. Clinical needs and realistic endpoints are taken into account. Furthermore, emerging strategies for the eradication of H. pylori and the existing evidence of their clinical validation and widespread applicability are discussed.

Helicobacter pylori Eradication Therapies in the Era of Increasing Antibiotic Resistance: A Paradigm Shift to Improved Efficacy

With the rising prevalence of antimicrobial resistance, the eradication rates of Helicobacter pylori (H. pylori) with standard treatments are decreasing to unacceptable levels (i.e., ≤80%) in most countries. After these disappointing results, several authorities have proposed that infection with H. pylori should be approached and treated as any other bacterial infectious disease. This implicates that clinicians should prescribe empirical treatments yielding a per protocol eradication of at least 90%. In recent years several treatments producing ≥90% cure rates have been proposed including sequential therapy, concomitant quadruple therapy, hybrid (dual-concomitant) therapy, and bismuth-containing quadruple therapy. These treatments are likely to represent the recommended first-line treatments in the near future. In the present paper, we are considering a series of critical issues regarding currently available means and approaches for the management of H. pylori infection. Clinical needs and realistic endpoints are taken into account. Furthermore, emerging strategies for the eradication of H. pylori and the existing evidence of their clinical validation and widespread applicability are discussed.

Fourth-line rescue therapy with rifabutin in patients with three Helicobacter pylori eradication failures

BACKGROUND

In some cases, Helicobacter pylori infection persists even after three eradication treatments.

AIM

To evaluate the efficacy of an empirical fourth-line rescue regimen with rifabutin in patients with three eradication failures.

DESIGN

Multicentre, prospective study.

PATIENTS

In whom the following three treatments had consecutively failed: first (PPI + clarithromycin + amoxicillin); second (PPI + bismuth + tetracycline + metronidazole); third (PPI + amoxicillin + levofloxacin).

INTERVENTION

A fourth regimen with rifabutin (150 mg b.d.), amoxicillin (1 g b.d.) and a PPI (standard dose b.d.) was prescribed for 10 days.

OUTCOME

Eradication was confirmed by (13) C-urea breath test 4-8 weeks after therapy. Compliance and tolerance: Compliance was determined through questioning and recovery of empty medication envelopes. Adverse effects were evaluated using a questionnaire.

RESULTS

One-hundred patients (mean age 50 years, 39% men, 31% peptic ulcer/69% functional dyspepsia) were included. Eight patients did not take the medication correctly (in six cases due to adverse effects). Per-protocol and intention-to-treat eradication rates were 52% (95% CI = 41-63%) and 50% (40-60%). Adverse effects were reported in 30 (30%) patients: nausea/vomiting (13 patients), asthenia/anorexia (8), abdominal pain (7), diarrhoea (5), fever (4), metallic taste (4), myalgia (4), hypertransaminasemia (2), leucopenia (<1,500 neutrophils) (2), thrombopenia (<150,000 platelets) (2), headache (1) and aphthous stomatitis (1). Myelotoxicity resolved spontaneously in all cases.

CONCLUSIONS

Even after three previous H. pylori eradication failures, an empirical fourth-line rescue treatment with rifabutin may be effective in approximately 50% of the cases. Therefore, rifabutin-based rescue therapy constitutes a valid strategy after multiple previous eradication failures with key antibiotics, such as clarithromycin, metronidazole, tetracycline and levofloxacin.

Rescue Therapy for Helicobacter pylori Infection 2012

Helicobacter pylori infection is the main cause of gastritis, gastroduodenal ulcer disease, and gastric cancer. After 30 years of experience in H. pylori treatment, however, the ideal regimen to treat this infection has still to be found. Nowadays, apart from having to know well first-line eradication regimens, we must also be prepared to face treatment failures. In designing a treatment strategy, we should not only focus on the results of primary therapy alone but also on the final-overall-eradication rate. The choice of a "rescue" treatment depends on which treatment is used initially. If a first-line clarithromycin-based regimen was used, a second-line metronidazole-based treatment (quadruple therapy) may be used afterwards, and then a levofloxacin-based combination would be a third-line "rescue" option. Alternatively, it has recently been suggested that levofloxacin-based "rescue" therapy constitutes an encouraging 2nd-line strategy, representing an alternative to quadruple therapy in patients with previous PPI-clarithromycin-amoxicillin failure, with the advantage of efficacy, simplicity and safety. In this case, quadruple regimen may be reserved as a 3rd-line "rescue" option. Even after two consecutive failures, several studies have demonstrated that H. pylori eradication can finally be achieved in almost all patients if several "rescue" therapies are consecutively given.

[Helicobacter pylori-related diseases: dyspepsia, ulcers and gastric cancer]

This article summarizes the main conclusions drawn from the presentations on Helicobacter pylori infection at Digestive Disease Week 2011. In developed countries, the prevalence of H. pylori infection has decreased, but seems to have reached a plateau at a fairly high level. Antibiotic resistance is increasing in several countries. H. pylori eradication does not contribute to the development of gastroesophageal reflux disease or worsen its course. The frequency of idiopathic peptic ulcers seems to be increasing. H. pylori eradication eliminates almost all episodes of peptic ulcer rebleeding; nevertheless, the use of non-steroidal anti-inflammatory drugs or H. pylori reinfection can lead to bleeding recurrence. H. pylori-negative patients with peptic ulcer bleeding more frequently have bleeding recurrences and higher mortality. In each particular population, there is a close correlation between the prevalence of H. pylori infection and the incidence of gastric cancer. H. pylori eradication is associated with a higher and faster healing rate of ulcerous lesions caused by endoscopic submucosal dissection. In patients undergoing endoscopic submucosal dissection for early gastric cancer, H. pylori eradication decreases the incidence of metachronous tumors. In a high proportion of cases, H. pylori eradication induces MALT lymphoma regression, and long-term tumoral recurrences are exceptional. Narrow-band imaging allows visualization of the mucous and vascular pattern in H. pylori-infected patients during the endoscopic examination. The electrochemical properties of H. pylori allow these lesions to be rapidly and accurately detected in gastric biopsies. The efficacy of "traditional" triple therapies currently leaves much to be desired. The superiority of "sequential" therapy over the standard triple therapy should be confirmed in distinct environments. The "concomitant" quadruple therapy seems to be as effective as "sequential" therapy, but with the advantage of being simpler. Both the "sequential" and the "concomitant" regimens are relatively effective even when clarithromycin resistance is present. Second-line rescue therapy with levofloxacin for 10 days is effective and is simpler and better tolerated than quadruple therapy. In patients allergic to penicillin, a combination with levofloxacin and clarithromycin is a promising rescue alternative. The new-generation quinolones, such as moxifloxacin and sitafloxacin, could be useful as eradication treatment. After two eradication treatment failures, an empirical third-line rescue therapy may be a valid option in clinical practice. Even after three previous H. pylori eradication failures, an empirical fourth-line rescue treatment with rifabutin may be effective.

Review article: rifabutin in the treatment of refractory Helicobacter pylori infection

BACKGROUND

Even with the current most effective treatment regimens, a relevant proportion of patients will fail to eradicate Helicobacter pylori infection.

AIM

To evaluate the role of rifabutin in the treatment of H. pylori infection.

METHODS

Bibliographical searches were performed in MEDLINE. Data on the efficacy of rifabutin-containing regimens on H. pylori eradication were combined and meta-analysed using the generic inverse variance method.

RESULTS

Rifabutin shows good in vitro activity against H. pylori. Mean H. pylori rifabutin resistance rate (calculated from 11 studies including 2982 patients) was 1.3% (95% confidence interval = 0.9-1.7%). When only studies including patients naïve to H. pylori eradication treatment were considered, this figure was even lower (0.6%). On the other hand, higher values of rifabutin resistance were calculated (1.59%) when only post-treatment patients were considered. Overall, mean H. pylori eradication rate (intention-to-treat analysis) with rifabutin-containing regimens (1008 patients) was 73% (67-79%). Respective cure rates for second-line (223 patients), third-line (342 patients) and fourth/fifth-line (95 patients) rifabutin therapies were 79% (67-92%), 66% (55-77%) and 70% (60-79%) respectively. For treating H. pylori infection, almost all studies have administered rifabutin 300 mg/day; this dose seems to be more effective than 150 mg/day. The ideal length of treatment remains unclear, but 10- to 12-day regimens are generally recommended. The mean rate of adverse effects was 22% (19-25%). Myelotoxicity is the most significant, although this complication was rare. Until now, all patients have recovered of leucopenia uneventfully in a few days, and there have been no reports of infection or other adverse outcomes related to it.

CONCLUSION

Rifabutin-containing rescue therapy constitutes an encouraging strategy after multiple (usually three) previous eradication failures with key antibiotics such as amoxicillin, clarithromycin, metronidazole, tetracycline and levofloxacin.

Review article: the effectiveness of standard triple therapy for Helicobacter pylori has not changed over the last decade, but it is not good enough

BACKGROUND  A decrease in the Helicobacter pylori eradication rate after standard triple therapy has been suggested in recent years. AIM  To assess the efficacy of standard triple therapy in the eradication of H. pylori through an epidemiological analysis of all published Spanish trials. A secondary aim was to review the prevalence of clarithromycin resistance in Spain. METHODS  Articles on H. pylori eradication in Spain published in peer-reviewed journals were identified through MEDLINE searches. Studies that included a triple therapy consisting of any proton pump inhibitor with clarithromycin (500 mg b.d.) and amoxicillin (1 g b.d.) for up to 14 days were selected. Spanish studies evaluating the prevalence of clarithromycin resistance were also reviewed. Meta-analysis was performed using the generic inverse variance method. RESULTS The pooled eradication rates by year from Spanish studies evaluating the efficacy of the standard triple regimen revealed a relatively constant rate over the years. Overall, the analysis of the 32 studies (4727 patients) showed a mean H. pylori cure rate of 80% (95% CI = 77-82%) by intention-to-treat and 83% (81-86%) by per-protocol. When only peptic ulcer disease or 7-day regimens were considered, results were similar. Based on 13 studies (3293 patients), mean clarithromycin resistance rate was 8% (5-10%). CONCLUSION Although a decrease in the H. pylori eradication rate after triple therapy has been suggested in recent years, cure rates with this regimen did not change in Spain between 1997 and 2008. However, this by no means indicates that the efficacy of standard triple therapy in Spain is acceptable, as it has been calculated to be around only 80%. Therefore, it is evident that new strategies to improve first-line treatment are urgently needed.

The oligo-acyl lysyl antimicrobial peptide C₁₂K-2β₁₂ exhibits a dual mechanism of action and demonstrates strong in vivo efficacy against Helicobacter pylori

Helicobacter pylori has developed antimicrobial resistance to virtually all current antibiotics. Thus, there is a pressing need to develop new anti-H. pylori therapies. We recently described a novel oligo-acyl-lysyl (OAK) antimicrobial peptidomimetic, C(12)K-2β(12), that shows potent in vitro bactericidal activity against H. pylori. Herein, we define the mechanism of action and evaluate the in vivo efficacy of C(12)K-2β(12) against H. pylori after experimental infection of Mongolian gerbils. We demonstrate using a 1-N-phenylnaphthylamine (fluorescent probe) uptake assay and electron microscopy that C(12)K-2β(12) rapidly permeabilizes the bacterial membrane and creates pores that cause bacterial cell lysis. Furthermore, using nucleic acid binding assays, Western blots, and confocal microscopy, we show that C(12)K-2β(12) can cross the bacterial membranes into the cytoplasm and tightly bind to bacterial DNA, RNA, and proteins, a property that may result in inhibition of enzymatic activities and macromolecule synthesis. To define the in vivo efficacy of C(12)K-2β(12), H. pylori-infected gerbils were orogastrically treated with increasing doses and concentrations of C(12)K-2β(12) 1 day or 1 week postinfection. The efficacy of C(12)K-2β(12) was strongest in animals that received the largest number of doses at the highest concentration, indicating dose-dependent activity of the peptide (P < 0.001 by analysis of variance [ANOVA]) regardless of the timing of the treatment with C(12)K-2β(12). Overall, our results demonstrate a dual mode of action of C(12)K-2β(12) against the H. pylori membrane and cytoplasmic components. Moreover, and consistent with the previously reported in vitro efficacy, C(12)K-2β(12) shows significant in vivo efficacy against H. pylori when used as monotherapy. Therefore, OAK peptides may be a valuable resource for therapeutic treatment of H. pylori infection.