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Zhao YR, Wang XJ, Zhu MJ, Chen AL, Zhang D, Du Q, Kim JJ, Hu WL. Efficacy and safety of low-dose tetracycline, amoxicillin quadruple therapy in Helicobacter pylori infection: A retrospective single center study. World J Gastroenterol 2024; 30:4295-4304. [DOI: 10.3748/wjg.v30.i39.4295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 09/09/2024] [Accepted: 09/24/2024] [Indexed: 10/12/2024] Open
Abstract
BACKGROUND Helicobacter pylori (H. pylori) eradication rates have declined with the rise of antibiotic-resistant strains in recent years. Although highly effective with a low prevalence of resistance, standard dose tetracycline is associated with frequent adverse events. The efficacy and safety of low-dose tetracycline as part of tetracycline and amoxicillin-containing bismuth quadruple therapy are not well described.
AIM To compare the efficacy and safety of low-dose compared to standard dose tetracycline with combined amoxicillin-containing bismuth quadruple therapy in patients with H. pylori infection.
METHODS Consecutive patients with H. pylori infection receiving tetracycline, amoxicillin, proton pump inhibitor, and bismuth for 14 days at Sir Run Run Shaw Hospital (1/2022-6/2023) were evaluated. The low-dose tetracycline group received tetracycline 500 mg twice daily (bid) while the standard dose group received 750 mg bid or 500 mg three times daily (tid). Primary endpoints were H. pylori eradication rate and treatment-related adverse events.
RESULTS The mean age of the 218 patients was 48.7 ± 14.0 years, 120 (55%) were male, and 118 (54.1%) received treatment as primary therapy. Furthermore, 73 (33%) patients received low-dose tetracycline (500 mg bid) and 145 (67%) received standard dose tetracycline including 500 mg tid in 74 (33%) and 750 mg bid in 71 (33%). On intention-to-treat analysis, H. pylori eradication rates were 89% [95% confidence interval (CI): 82%-96%] in the 500 mg bid group, 82% (95%CI: 74%-91%) in the 500 mg tid group, and 79% (95%CI: 69%-89%) in the 750 mg bid group without a statistically significant difference (P = 0.25). The incidence of adverse events was lower in the low-dose compared to the standard dose group (12.3% vs 31.1% or 23.9%; P = 0.02).
CONCLUSION Low-dose tetracycline combined with amoxicillin quadruple therapy for 14 days achieved a high eradication rate and fewer adverse events compared to the standard dose tetracycline regimen in patients with H. pylori infection.
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Affiliation(s)
- Yi-Ru Zhao
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
- Department of Gastroenterology, The First Affiliated Hospital, Medical School, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Xin-Jie Wang
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Meng-Jia Zhu
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Ang-Li Chen
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Dian Zhang
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Qin Du
- Department of Gastroenterology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - John J Kim
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90089-9021, United States
| | - Wei-Ling Hu
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
- Institute of Gastroenterology, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
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Sun YC, Zhu MJ, Chen XQ, Yue L, Zhao YR, Wang XJ, Kim JJ, Du Q, Hu WL. Efficacy and safety of modified tetracycline dosing in a quadruple therapy for Helicobacter pylori: A retrospective single center study. World J Gastroenterol 2023; 29:3508-3518. [PMID: 37389237 PMCID: PMC10303514 DOI: 10.3748/wjg.v29.i22.3508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/09/2023] [Accepted: 05/15/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Although highly effective as a component of Helicobacter pylori (H. pylori) treatment regimen, tetracycline is associated with a high incidence of medication-related adverse events. Modified dosing of tetracycline as part of quadruple therapy may improve safety while providing comparable eradication rates. AIM To evaluate the efficacy and safety of modified dosing of tetracycline in patients receiving tetracycline and furazolidone-containing quadruple therapy in patients with H. pylori infection. METHODS Consecutive patients (10/2020-12/2021) who received tetracycline and furazolidone quadruple therapy for H. pylori infection at Sir Run Run Shaw Hospital were identified. All patients received tetracycline, furazolidone, proton pump inhibitor, and bismuth for 14 d as primary or rescue therapy. Modified tetracycline dose group received tetracycline 500 mg twice daily while standard group received 750 mg twice daily or 500 mg three times daily. RESULTS Three hundred and ninety-four patients [mean age = 46.3 ± 13.9, male = 137 (34.8%), and 309 (78.4%) primary therapy] completed tetracycline and furazolidone quadruple therapy for H. pylori infection including those who received modified tetracycline dose in 157 and standard doses in 118 (750 mg twice daily) and 119 (500 mg three times daily). Eradication rates in the modified tetracycline dose group were 92.40% and in the standard groups, eradication rates were 93.20% for 750 mg twice daily group and 92.43% for 500 mg three times daily group, respectively, without statistical difference (P = 0.959). The incidence of adverse events was lower in the modified tetracycline dose (15.3% vs 32.3% and 29.4%; P = 0.002) compared to the standard dose group. CONCLUSION In a real-world experience, modified tetracycline dosing as part of tetracycline and furazolidone quadruple therapy for 14 d demonstrated high efficacy, comparable to standard tetracycline dose regimens, with a favorable safety profile.
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Affiliation(s)
- Ying-Chao Sun
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Meng-Jia Zhu
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Xue-Qin Chen
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Lei Yue
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Yi-Ru Zhao
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Xin-Jie Wang
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - John J Kim
- Division of Gastroenterology, Loma Linda University Health, Loma Linda, CA 92354, United States
| | - Qin Du
- Department of Gastroenterology, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou 310009, Zhejiang Province, China
| | - Wei-Ling Hu
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
- Institute of Gastroenterology, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
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Kim SE. Approach to Patients with Consecutive Helicobacter pylori Eradication Failure. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2023. [DOI: 10.7704/kjhugr.2023.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
<i>Helicobacter pylori</i> (<i>H. pylori</i>) is associated with various gastrointestinal disorders, such as gastritis, peptic ulcers, mucosa-associated lymphoid tissue lymphoma, and gastric cancer. Therefore, the International Agency for Research on Cancer, a specialized cancer agency of the World Health Organization, categorizes <i>H. pylori</i> as a definite gastric carcinogen (group I). <i>H. pylori</i> eradication is a major challenge both medically and socioeconomically in countries with high prevalence of <i>H. pylori</i> and gastric cancer. However, the efficacy of first-line clarithromycin-containing triple therapy and second-line bismuth-containing quadruple therapy continues to decline worldwide including in Korea. The role of salvage therapy is being recognized globally; however, the exact salvage therapy which is useful in daily clinical practice remains unestablished. In this review, factors associated with eradication failure will be discussed. Furthermore, eradication regimens that may be useful as salvage therapies based on Korean guidelines, Maastricht VI/Florence consensus report and previous research are summarized.
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Dore MP, Saba F, Zanni L, Rocca A, Piroddu J, Gutierrez G, Pes GM. A Simplified Low-Dose 10-Day Quadruple Therapy with a Galenic Formulation of Bismuth Salicylate Is Highly Effective for Helicobacter pylori Eradication. J Clin Med 2023; 12:jcm12020681. [PMID: 36675610 PMCID: PMC9861798 DOI: 10.3390/jcm12020681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Earlier studies have shown that a modified low-dose bismuth quadruple therapy given for 10 to 14 days is highly effective for the treatment of Helicobacter pylori infection in Sardinia. However, bismuth is not universally available. AIM We aimed to investigate the efficacy of a simplified low-dose 10-day quadruple therapy containing a galenic formulation of bismuth salicylate for H. pylori infection. PATIENTS AND METHODS Adult patients positive for H. pylori infection were assigned to a quadruple therapy containing a galenic formulation of bismuth salicylate (200 mg) plus tetracycline 500 mg, metronidazole 500 mg and rabeprazole 20 mg, given twice a day with the midday and evening meals for 10 days. A negative stool antigen test or 13C-Urea Breath Test defined successful eradication. Compliance and adverse events were recorded 30-40 days after the end of treatment. RESULTS In this open-label pilot study, 42 patients were enrolled (mean age 54.1 ± 12.0 years; 64% female). Among the study participants, 35 were naïve to H. pylori treatment. The treatment regimen was completed by 41 patients, with an overall success rate of 95.1%. More specifically, the eradication rate was 95.1% PP; 95% confidence interval (CI) = 86.6-100 and 92.9% by ITT; 95%CI = 85.1-100%, respectively. For naïve patients, the cure rate was 97.1%. Compliance was excellent. Side effects were absent or mild overall. CONCLUSIONS The modified low-dose 10-day quadruple therapy provided high eradication rates of H. pylori infection, despite the replacement of colloidal bismuth subcitrate with bismuth salicylate. In regions where bismuth is unavailable in the market, the galenic formulation should be a valid option.
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Affiliation(s)
- Maria Pina Dore
- Dipartimento di Medicina, Chirurgia e Farmacia, Clinica Medica, University of Sassari, Viale San Pietro 8, 07100 Sassari, Italy
- Department of Medicine, Baylor College of Medicine, One Baylor Plaza Blvd, Houston, TX 77030, USA
- Correspondence: ; Tel.: +39-079-229886
| | - Francesco Saba
- Dipartimento di Medicina, Chirurgia e Farmacia, Clinica Medica, University of Sassari, Viale San Pietro 8, 07100 Sassari, Italy
| | - Lucia Zanni
- Dipartimento di Medicina, Chirurgia e Farmacia, Clinica Medica, University of Sassari, Viale San Pietro 8, 07100 Sassari, Italy
| | - Anna Rocca
- Dipartimento di Medicina, Chirurgia e Farmacia, Clinica Medica, University of Sassari, Viale San Pietro 8, 07100 Sassari, Italy
| | - Jessica Piroddu
- Dipartimento di Medicina, Chirurgia e Farmacia, Clinica Medica, University of Sassari, Viale San Pietro 8, 07100 Sassari, Italy
| | | | - Giovanni Mario Pes
- Dipartimento di Medicina, Chirurgia e Farmacia, Clinica Medica, University of Sassari, Viale San Pietro 8, 07100 Sassari, Italy
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Efficacy of Twice a Day Bismuth Quadruple Therapy for Second-Line Treatment of Helicobacter pylori Infection. J Pers Med 2022; 12:jpm12010056. [PMID: 35055371 PMCID: PMC8778712 DOI: 10.3390/jpm12010056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 11/22/2022] Open
Abstract
Bismuth quadruple therapy (BQT) is an effective treatment for Helicobacter pylori infection. However, frequent dosing schedules of BQT regimen often compromise drug adherence and may affect treatment outcomes. This retrospective study aimed to investigate the efficacy of twice-daily BQT compared to that of four times a day therapy. From August 2018 to November 2020, adult patients who failed first-line standard triple therapy and underwent BQT were eligible. Patients were categorized into two groups according to dosing schedule: (i) the BQT group (n = 213) who received standard BQT administered four times a day; and (ii) the BQTb group (n = 141) who received proton pump inhibitor, bismuth 600 mg, metronidazole 500 mg, and tetracycline 1 g twice a day. The eradication rate did not differ between the BQT (92.5%) and the BQTb groups (90.1%) (p = 0.441). Adherence and adverse event rate were similar between the two groups. Multivariate analysis showed that current smoking was associated with eradication failure; however, dosing frequency was not associated with the efficacy of eradication therapy. This study suggested that twice a day BQT is as effective as four times a day therapy for second-line treatment of H. pylori infection.
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Ozturk MA, Koroglu M, Ayvaz MA. The efficacy of bismuth quadruple therapy, sequential therapy, and hybrid therapy as a first-line regimen for Helicobacter pylori infection compared with standard triple therapy. Niger J Clin Pract 2022; 25:1535-1541. [DOI: 10.4103/njcp.njcp_89_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kim YJ, Chung WC. Bismuth-containing Standard Triple Therapy the First-line Eradication Therapy for Helicobacter pylori. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2021. [DOI: 10.7704/kjhugr.2021.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Kim JY, Lee SY, Kim JH, Sung IK, Park HS. Efficacy and safety of twice a day, bismuth-containing quadruple therapy using high-dose tetracycline and metronidazole for second-line Helicobacter pylori eradication. Helicobacter 2020; 25:e12683. [PMID: 32074663 DOI: 10.1111/hel.12683] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/14/2020] [Accepted: 02/03/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIMS Conventional second-line, bismuth-containing quadruple therapy is administered four times a day. We aimed to evaluate the efficacy and safety of twice a day administration compared to the four times a day therapy. METHODS Medical records of consecutive patients with positive 13 C-urea breath tests (UBTs) after first-line eradication were reviewed. From December 2018 to June 2019, 100 consecutive 13 C-UBT-positive patients received tetracycline 1 g, metronidazole 750 mg, bismuth subcitrate 300 mg, and pantoprazole 20 mg twice a day for one week. The same number of consecutive13 C-UBT-positive patients before December 2018 was included as controls. The control group received tetracycline 500 mg and bismuth subcitrate 300 mg four times a day, metronidazole 500 mg three times a day, and pantoprazole 20 mg twice a day for one week. Eradication was confirmed based on a 13 C-UBT performed in the 5th week after taking quadruple therapy. RESULTS Ninety-eight patients from the twice a day group and 99 patients from the four times a day group were analyzed. The eradication rate did not differ between the twice a day group (92/98, 93.9%) and the four times a day group (92/99, 92.9%). Adverse drug effects were found in 36 patients from the twice a day group and 50 patients from the four times a day group (P = .051). Abdominal pain, discomfort, and distention were more common with four times a day intake (13.1%) than with twice a day intake (4.1%; P = .024). CONCLUSIONS We determined for the first time that twice a day intake of bismuth-containing quadruple therapy using 2 g/d of tetracycline, 1.5 g/d of metronidazole, and 600 mg/d of bismuth subcitrate for one week is effective and safe as the conventional four times a day therapy. Twice a day intake decreased abdominal pain, discomfort, and distention.
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Affiliation(s)
- Ji Yeon Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Sun-Young Lee
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jeong Hwan Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - In-Kyung Sung
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Hyung Seok Park
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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Dore MP, Bibbò S, Loria M, Salis R, Manca A, Pes GM, Graham DY. Twice-a-day PPI, tetracycline, metronidazole quadruple therapy with Pylera® or Lactobacillus reuteri for treatment naïve or for retreatment of Helicobacter pylori. Two randomized pilot studies. Helicobacter 2019; 24:e12659. [PMID: 31502382 DOI: 10.1111/hel.12659] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/14/2019] [Accepted: 08/13/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bismuth is no longer available in Europe except as part of combination therapy. Lactobacillus reuteri has also been used as an adjuvant for Helicobacter pylori therapy. We aimed to investigate the efficacy of a b.i.d. quadruple therapy containing Pylera® or L reuteri for H pylori infection. MATERIALS AND METHODS We performed two open-label randomized pilot studies. Adult patients positive for H pylori were randomly assigned to b.i.d therapy with quadruple therapy containing bismuth (2 capsules of Pylera® plus 250 mg each of tetracycline and metronidazole for a total of 500 mg of each), or the same dose of antibiotics plus 2 × 108 CFU L reuteri DSM 17 938 plus 2 × 108 CFU L reuteri ATCC PTA 6475 (Gastrus®) once daily and pantoprazole 20 mg b.i.d. Regimens were given with meals for 10 days. Cure was defined by negative 13C-UBT or stool antigen test. RESULTS A total of 99 subjects (29% men) were enrolled; 92 completed the study. In the Pylera® group, H pylori infection was cured in 95.7%; 95% CI = 85%-99% (44/46) PP and 88%; 95% CI = 75%-95% (44/50) ITT vs. 84.8%; 95% CI = 71%-95% (39/46) PP and 79.6%; 95% CI = 65%-89% (39/49) ITT in the Gastrus® group, respectively. Cure rates in naїve patients were 100%; 95% CI = 85%-100% (25/25) PP with Pylera®, and 89.7%; 95% CI = 72%-97% (26/29) with Gastrus®. Compliance was excellent and side effects mild with both regimens. CONCLUSIONS B.i.d. bismuth quadruple therapy was highly effective for H pylori eradication in treatment of naïve patients in Sardinia. Replacement of bismuth with Gastrus® might be considered when bismuth is contraindicated or unavailable.
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Affiliation(s)
- Maria Pina Dore
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, University of Sassari, Italy.,Baylor College of Medicine, Houston, Texas
| | - Stefano Bibbò
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, University of Sassari, Italy
| | - Mariafrancesca Loria
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, University of Sassari, Italy
| | - Roberta Salis
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, University of Sassari, Italy
| | - Alessandra Manca
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, University of Sassari, Italy
| | - Giovanni Mario Pes
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, University of Sassari, Italy
| | - David Yates Graham
- Baylor College of Medicine, Houston, Texas.,Department of Medicine, Michael E. DeBakey VAMC, Houston, Texas
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Graham DY, Dore MP, Lu H. Understanding treatment guidelines with bismuth and non-bismuth quadruple Helicobacter pylori eradication therapies. Expert Rev Anti Infect Ther 2018; 16:679-687. [PMID: 30102559 DOI: 10.1080/14787210.2018.1511427] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Recent Helicobacter pylori treatment guidelines recommend the 4-drug combinations bismuth quadruple therapy and concomitant therapy. Areas covered: We review antimicrobial therapy for H. pylori in the context of antimicrobial therapy in general and specifically in relation to good antimicrobial stewardship (defined as optimal selection, dose, and duration of an antimicrobial that results in the best clinical outcome for the treatment of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance). Expert commentary: The lack of regional and local H. pylori susceptibility data prevents implementation of susceptibility-based antimicrobial therapy and forces compromises. Bismuth quadruple therapy employing at least 1,500 mg of metronidazole for 14 days is effective despite metronidazole resistance. The main drawback is side effects causing reduced adherence. Versions where amoxicillin replaces metronidazole or tetracycline also appear effective. It is likely that bismuth quadruple therapy can be simplified by giving bismuth and possibly tetracycline b.i.d., possibly with fewer side effects. Concomitant therapy (a proton pump inhibitor, metronidazole, clarithromycin, amoxicillin) is ineffective with dual clarithromycin-metronidazole resistance and all patients receive at least one unnecessary antibiotic thus promoting antimicrobial resistance worldwide. Concomitant therapy should be abandoned when susceptibility testing becomes widespread or an alternate becomes available.
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Affiliation(s)
- David Y Graham
- a Department of Medicine , Michael E. DeBakey VA Medical Center and Baylor College of Medicine , Houston , TX , USA
| | - Maria Pina Dore
- b Dipartimento di Medicina Clinica e Sperimentale, Clinica Medica , University of Sassari , Sassari , Italy
| | - Hong Lu
- c Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, GI Division, Ren Ji Hospital, School of medicine , Shanghai Jiao Tong University, Shanghai Institution of Digestive Disease , Shanghai , China
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Abstract
Bismuth salts exert their activity within the upper gastrointestinal tract through action of luminal bismuth. Bismuth exerts direct bactericidal effect on Helicobacter pylori by different ways: forms complexes in the bacterial wall and periplasmic space, inhibits different enzymes, ATP synthesis, and adherence of the bacteria to the gastric mucosa. Bismuth also helps ulcer healing by acting as a barrier to the aggressive factors and increasing mucosal protective factors such as prostaglandin, epidermal growth factor, and bicarbonate secretion. To date, no resistance to bismuth has been reported. Also synergism between bismuth salts and antibiotics was present. It was shown that metronidazole and clarithromycin resistant H. pylori strains become susceptible if they are administered together with bismuth. Bismuth-containing quadruple therapy was recommended both by the Second Asia-Pacific Consensus Guidelines and by the Maastricht IV/Florence Consensus Report as an alternative first choice regimen to standard triple therapy, in areas with low clarithromycin resistance, and it is recommended as the first-line therapeutic option in areas with a high prevalence of clarithromycin resistance. Greater than 90% eradication success can be obtained by bismuth-containing quadruple therapy. Choosing bismuth as an indispensable part of first-line therapy is logical as both metronidazole and clarithromycin resistances can be overcome by adding bismuth to the regimen.
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Muller N, Amiot A, Le Thuaut A, Bastuji-Garin S, Deforges L, Delchier JC. Rescue therapy with bismuth-containing quadruple therapy in patients infected with metronidazole-resistant Helicobacter pylori strains. Clin Res Hepatol Gastroenterol 2016; 40:517-24. [PMID: 26850363 DOI: 10.1016/j.clinre.2015.12.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 12/11/2015] [Accepted: 12/25/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND The emergence of H. pylori strains that are resistant to clarithromycin, metronidazole and fluoroquinolone requires the evaluation of new and effective salvage therapies. AIMS To test the efficacy of a new formulation of a bismuth-containing quadruple therapy as a rescue therapy in patients who were infected with a H. pylori strain resistant to metronidazole, clarithromycin and fluoroquinolone or who failed multiple lines of treatment using these three antibiotics. METHODS A total of 103 patients with confirmed H. pylori infection with a resistance profile described above were treated with Pylera(®) (3-in-1 capsules containing bismuth subcitrate potassium 140mg, metronidazole 125mg and tetracycline 125mg) 3 capsules four times a day plus omeprazole 20mg two times a day for 10 days in a named patient program. Eradication was confirmed using a urea breath test at least 28 days after the end of treatment. Efficacy and safety were studied. RESULTS A total of 103 patients were prospectively included from June 2010 to October 2011. The eradication rate for the intent-to-treat analysis was 83% (CI95%[75-89%]); an 87% eradication rate (CI95%[80-94%]) was found for the per-protocol analysis and 81% (CI95%[80-82%]) for the intent-to-treat analysis in patients with proven resistance to metronidazole. Nine patients discontinued treatment, all due to adverse events. Two serious adverse events (AEs) were reported (memory disorders of unknown significance). Fifty-six (54%) patients reported at least one AE. CONCLUSION This bismuth-containing quadruple therapy achieved a remarkable eradication rate as a salvage therapy in patients infected with metronidazole-resistant H. pylori strain, despite the frequent occurrence of mild-to-moderate adverse events.
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Affiliation(s)
- Nelly Muller
- Department of Gastroenterology, Assistance publique-Hôpitaux de Paris (AP-HP), Paris Est Creteil University (UPEC), Henri-Mondor Hospital, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Creteil, France
| | - Aurélien Amiot
- Department of Gastroenterology, Assistance publique-Hôpitaux de Paris (AP-HP), Paris Est Creteil University (UPEC), Henri-Mondor Hospital, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Creteil, France; Laboratory of Clinical Investigation (LIC, EA 4393), Paris Est Creteil University (UPEC), 94010 Creteil, France
| | - Aurélie Le Thuaut
- Laboratory of Clinical Investigation (LIC, EA 4393), Paris Est Creteil University (UPEC), 94010 Creteil, France; Department of Public Health, Assistance publique-Hôpitaux de Paris (AP-HP), Henri-Mondor Hospital, 94010 Creteil, France; Clinical Research Unit (URC Mondor), Assistance publique-Hôpitaux de Paris (AP-HP), Henri-Mondor Hospital, Creteil, France
| | - Sylvie Bastuji-Garin
- Laboratory of Clinical Investigation (LIC, EA 4393), Paris Est Creteil University (UPEC), 94010 Creteil, France; Department of Public Health, Assistance publique-Hôpitaux de Paris (AP-HP), Henri-Mondor Hospital, 94010 Creteil, France; Clinical Research Unit (URC Mondor), Assistance publique-Hôpitaux de Paris (AP-HP), Henri-Mondor Hospital, Creteil, France
| | - Lionel Deforges
- Laboratory of microbiology Research Unit (URC Mondor), Assistance publique-Hôpitaux de Paris (AP-HP), Henri-Mondor Hospital, Creteil, France
| | - Jean-Charles Delchier
- Department of Gastroenterology, Assistance publique-Hôpitaux de Paris (AP-HP), Paris Est Creteil University (UPEC), Henri-Mondor Hospital, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Creteil, France.
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Dore MP, Soro S, Rocchi C, Loria MF, Bibbò S, Pes GM. Inclusion of Lactobacillus Reuteri in the Treatment of Helicobacter pylori in Sardinian Patients: A Case Report Series. Medicine (Baltimore) 2016; 95:e3411. [PMID: 27082621 PMCID: PMC4839865 DOI: 10.1097/md.0000000000003411] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Clinical studies have shown that bismuth-containing quadruple therapy given twice a day for 10 to 14 days is effective and safe in the treatment of Helicobacter pylori infection in Sardinia. However, bismuth is no longer available in Italy. To report the effectiveness and tolerability of pantoprazole 20 mg, tetracycline 500 mg, and metronidazole 500 mg given b.i.d. (with the midday and evening meals) for 10 days supplemented with Lactobacillus reuteri (DSM 17938) 10(8) cfu/tablet once a day for 20 days in patients treated in a routine daily practice setting. H pylori infection was defined as a positive gastric histopathology and/or 13C-Urea Breath Test (UBT) and/or stool antigen testing. Successful eradication was documented by 13C-UBT, and/or stool antigen assay at least 4 weeks post-therapy. Compliance and side effects were recorded after completing treatment. A total of 45 patients (10 men, 35 women; mean age 52.6 years) have completed the treatment regimen with the success rate of 93% (95% confidence interval = 85-99%). Compliance was excellent. Side effects were absent or generally mild.Proton pump inhibitor-tetracycline-metronidazole-L reuteri therapy provided high eradication rates with few side effects and therefore can safely replace bismuth in H pylori treatment. Further studies are needed that include susceptibility testing.
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Affiliation(s)
- Maria P Dore
- From the Department of Clinical and Experimental Medicine (MPD, SS, CR, MFL, SB, GMP), University of Sassari, Sassari Italy; and Baylor College of Medicine (MPD), Houston, TX
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Graham DY, Lee SY. How to Effectively Use Bismuth Quadruple Therapy: The Good, the Bad, and the Ugly. Gastroenterol Clin North Am 2015; 44:537-63. [PMID: 26314667 PMCID: PMC4555994 DOI: 10.1016/j.gtc.2015.05.003] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bismuth triple therapy was the first effective Helicobacter pylori eradication therapy. The addition of a proton pump inhibitor helped overcome metronidazole resistance. Its primary indication is penicillin allergy or when clarithromycin and metronidazole resistance are both common. Resistance to the primary first-line therapy have centered on complexity and difficulties with compliance. Understanding regional differences in effectiveness remains unexplained because of the lack of studies including susceptibility testing and adherence data. We discuss regimen variations including substitutions of doxycycline, amoxicillin, and twice a day therapy and provide suggestions regarding what is needed to rationally and effectively use bismuth quadruple therapy.
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Affiliation(s)
- David Y. Graham
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Sun-Young Lee
- Department of Internal Medicine, Konkuk University School of Medicine, 120-1 Neungdong-ro, Seoul 143-729, Korea
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15
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Gisbert JP, Romano M, Gravina AG, Solís-Muñoz P, Bermejo F, Molina-Infante J, Castro-Fernández M, Ortuño J, Lucendo AJ, Herranz M, Modolell I, Del Castillo F, Gómez J, Barrio J, Velayos B, Gómez B, Domínguez JL, Miranda A, Martorano M, Algaba A, Pabón M, Angueira T, Fernández-Salazar L, Federico A, Marín AC, McNicholl AG. Helicobacter pylori second-line rescue therapy with levofloxacin- and bismuth-containing quadruple therapy, after failure of standard triple or non-bismuth quadruple treatments. Aliment Pharmacol Ther 2015; 41:768-75. [PMID: 25703120 DOI: 10.1111/apt.13128] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 11/22/2014] [Accepted: 01/29/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND The most commonly used second-line Helicobacter pylori eradication regimens are bismuth-containing quadruple therapy and levofloxacin-containing triple therapy, both offering suboptimal results. Combining bismuth and levofloxacin may enhance the efficacy of rescue eradication regimens. AIMS To evaluate the efficacy and tolerability of a second-line quadruple regimen containing levofloxacin and bismuth in patients whose previous H. pylori eradication treatment failed. METHODS This was a prospective multicenter study including patients in whom a standard triple therapy (PPI-clarithromycin-amoxicillin) or a non-bismuth quadruple therapy (PPI-clarithromycin-amoxicillin-metronidazole, either sequential or concomitant) had failed. Esomeprazole (40 mg b.d.), amoxicillin (1 g b.d.), levofloxacin (500 mg o.d.) and bismuth (240 mg b.d.) was prescribed for 14 days. Eradication was confirmed by (13) C-urea breath test. Compliance was determined through questioning and recovery of empty medication envelopes. Incidence of adverse effects was evaluated by questionnaires. RESULTS 200 patients were included consecutively (mean age 47 years, 67% women, 13% ulcer). Previous failed therapy included: standard clarithromycin triple therapy (131 patients), sequential (32) and concomitant (37). A total of 96% took all medications correctly. Per-protocol and intention-to-treat eradication rates were 91.1% (95%CI = 87-95%) and 90% (95%CI = 86-94%). Cure rates were similar regardless of previous (failed) treatment or country of origin. Adverse effects were reported in 46% of patients, most commonly nausea (17%) and diarrhoea (16%); 3% were intense but none was serious. CONCLUSIONS Fourteen-day bismuth- and levofloxacin-containing quadruple therapy is an effective (≥90% cure rate), simple and safe second-line strategy in patients whose previous standard triple or non-bismuth quadruple (sequential or concomitant) therapies have failed.
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Affiliation(s)
- J P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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16
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Qiu KJ, Liu Y, Zhou FY, Wang BL, Li L, Zheng YF, Liu YH. Microstructure, mechanical properties, castability and in vitro biocompatibility of Ti-Bi alloys developed for dental applications. Acta Biomater 2015; 15:254-65. [PMID: 25595472 DOI: 10.1016/j.actbio.2015.01.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 12/19/2014] [Accepted: 01/02/2015] [Indexed: 12/30/2022]
Abstract
In this study, the microstructure, mechanical properties, castability, electrochemical behaviors, cytotoxicity and hemocompatibility of Ti-Bi alloys with pure Ti as control were systematically investigated to assess their potential applications in the dental field. The experimental results showed that, except for the Ti-20Bi alloy, the microstructure of all other Ti-Bi alloys exhibit single α-Ti phase, while Ti-20Bi alloy is consisted of mainly α-Ti phase and a small amount of BiTi2 and BiTi3 phases. The tensile strength, hardness and wear resistance of Ti-Bi alloys were demonstrated to be improved monotonically with the increase of Bi content. The castability test showed that Ti-2Bi alloy increased the castability of pure Ti by 11.7%. The studied Ti-Bi alloys showed better corrosion resistance than pure Ti in both AS (artificial saliva) and ASFL (AS containing 0.2% NaF and 0.3% lactic acid) solutions. The concentrations of both Ti ion and Bi ion released from Ti-Bi alloys are extremely low in AS, ASF (AS containing 0.2% NaF) and ASL (AS containing 0.3% lactic acid) solutions. However, in ASFL solution, a large number of Ti and Bi ions are released. In addition, Ti-Bi alloys produced no significant deleterious effect to L929 cells and MG63 cells, similar to pure Ti, indicating a good in vitro biocompatibility. Besides, both L929 and MG63 cells perform excellent cell adhesion ability on Ti-Bi alloys. The hemolysis test exhibited that Ti-Bi alloys have an ultra-low hemolysis percentage below 1% and are considered nonhemolytic. To sum up, the Ti-2Bi alloy exhibits the optimal comprehensive performance and has great potential for dental applications.
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Affiliation(s)
- K J Qiu
- Center for Biomedical Materials and Engineering, Harbin Engineering University, Harbin 150001, China
| | - Y Liu
- Department of Materials Science and Engineering, College of Engineering, Peking University, Beijing 100871, China
| | - F Y Zhou
- Center for Biomedical Materials and Engineering, Harbin Engineering University, Harbin 150001, China
| | - B L Wang
- Center for Biomedical Materials and Engineering, Harbin Engineering University, Harbin 150001, China
| | - L Li
- Center for Biomedical Materials and Engineering, Harbin Engineering University, Harbin 150001, China
| | - Y F Zheng
- Center for Biomedical Materials and Engineering, Harbin Engineering University, Harbin 150001, China; Department of Materials Science and Engineering, College of Engineering, Peking University, Beijing 100871, China.
| | - Y H Liu
- General Dental Department, School of Stomatology, Peking University, Beijing 100081, China
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17
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Dore MP, Cuccu M, Pes GM, Manca A, Graham DY. Lactobacillus reuteri in the treatment of Helicobacter pylori infection. Intern Emerg Med 2014; 9:649-54. [PMID: 24178436 DOI: 10.1007/s11739-013-1013-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 10/21/2013] [Indexed: 12/12/2022]
Abstract
Probiotics have proven to be useful in the treatment of a number of gastrointestinal diseases. Probiotics may compete directly with Helicobacter pylori, possibly by interference with adherence or by the production of antimicrobial molecules. Lactobacillus reuteri has been shown to inhibit H. pylori in vitro and in vivo, and theoretically may play a role in eradication therapy. The aim of this study was to examine the efficacy of L. reuteri in H. pylori eradication therapy. This was an open label single center study. H. pylori infection was defined as positive gastric histopathology and (13)C-UBT. Intervention consisted of L. reuteri (DSM 17938) 10(8) cfu plus pantoprazole 20 mg twice a day for 8 weeks. Eradication was defined as a negative (13)C-UBT, 4-6 weeks post therapy. Compliance was considered good if at least 90% of the total number of the pills were taken. 21 of 22 subjects completed the study without protocol violation (mean age 52 years; 36% men). L. reuteri plus pantoprazole twice a day cured 13.6% (3/22; 95% CI 2.9-34.9%) of patients with H. pylori infection by ITT analysis and 14.2% (3/21; 95% CI 3.0-36%) by PP analysis. Overall urease activity assessed before and 4-6 weeks post therapy showed a significant reduction with a difference of mean of 38.8 vs. 25.4 by one-tailed test (P = 0.002). In conclusion, L. reuteri may have a potential role in H. pylori eradication therapy if the cure rate can be improved by changes in dose, dosing interval, or duration of therapy.
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Affiliation(s)
- Maria Pina Dore
- Dipartimento di Medicina Clinica e Sperimentale, Clinica Medica, University of Sassari, Viale San Pietro 8, 07100, Sassari, Italy,
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Heo J, Jeon SW. Optimal treatment strategy for Helicobacter pylori: Era of antibiotic resistance. World J Gastroenterol 2014; 20:5654-5659. [PMID: 24914324 PMCID: PMC4024773 DOI: 10.3748/wjg.v20.i19.5654] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 11/29/2013] [Accepted: 02/20/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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19
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Xiao SP, Gu M, Zhang GX. Is levofloxacin-based triple therapy an alternative for first-line eradication of Helicobacter pylori? A systematic review and meta-analysis. Scand J Gastroenterol 2014; 49:528-38. [PMID: 24611790 DOI: 10.3109/00365521.2014.887765] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To evaluate the available data on the efficacy and safety of levofloxacin-based triple therapy compared with standard triple therapy in first-line treatment for Helicobacter pylori infection. METHODS By searching MEDLINE, The Cochrane Central Register of Controlled Trials, and Web of Knowledge, two independent reviewers systemically identified randomized controlled trials comparing levofloxacin-based triple regimen with standard triple therapy for first-line treatment of H. pylori infection. The pooled risk ratios (RR) and 95% confidence intervals were calculated. RESULTS Overall, nine randomized controlled trials including 1275 patients have been treated with levofloxacin-based triple therapy and 1237 patients with standard regimen. Eradication rate in the levofloxacin-based therapy group was slightly higher than that in the standard triple therapy group regardless of treatment duration (80.2% vs. 77.4%, RR=1.03, 95% CI=0.94-1.13). Subgroup analysis related to different geographic areas found that efficacy of 7-day standard triple regimen was statistically superior to 7-day levofloxacin-based scheme in Asian group (RR=0.91, 95% CI=0.86-0.97), but levofloxacin-based triple therapy was predominant regardless of treatment time in European countries (RR=1.15, 95% CI=1.06-1.23). There was no significant difference between two groups in the incidence of overall adverse events or in the occurrence of discontinuing therapy due to side effects. CONCLUSIONS The 10-day levofloxacin-based triple therapy may be considered as an alternative for increasing cure rate of H. pylori infection in European areas. But in Asian countries, standard triple regimen is still superior to levofloxacin-based therapy as first-line regimen for H. pylori eradication.
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Affiliation(s)
- Shu-Ping Xiao
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University , Nanjing , China
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20
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Gisbert JP, Perez-Aisa A, Rodrigo L, Molina-Infante J, Modolell I, Bermejo F, Castro-Fernández M, Antón R, Sacristán B, Cosme A, Barrio J, Harb Y, Gonzalez-Barcenas M, Fernandez-Bermejo M, Algaba A, Marín AC, McNicholl AG. Third-line rescue therapy with bismuth-containing quadruple regimen after failure of two treatments (with clarithromycin and levofloxacin) for H. pylori infection. Dig Dis Sci 2014; 59:383-9. [PMID: 24126798 DOI: 10.1007/s10620-013-2900-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 09/25/2013] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- J P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa and Instituto de Investigación Sanitaria Princesa (IP), Playa de Mojácar 29. Urb. Bonanza., 28669, Boadilla del Monte, Madrid, Spain,
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21
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Wu JY, Liou JM, Graham DY. Evidence-based recommendations for successful Helicobacter pylori treatment. Expert Rev Gastroenterol Hepatol 2014; 8:21-8. [PMID: 24410470 DOI: 10.1586/17474124.2014.859522] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
An effective Helicobacter pylori therapy reliably provides high cure rates in infections with susceptible strains. It is possible to predict the efficacy of any regimen if one knows the prevalence of antibiotic resistance for a regimen or for a specific patient. We show how to predict the outcome for current regimens and discuss the factors that undermine different regimens (i.e., their Achilles heel). In general, in Western countries, clarithromycin-containing triple and sequential therapy should be considered obsolete as empiric therapies. Preferred regimens are 14-day concomitant or bismuth-containing quadruple therapy. We provide details of how to identify a regimen for a patient or region that will reliably cure 90% or more as well as those that will reliably fail.
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Affiliation(s)
- Jeng-Yih Wu
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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22
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Dore MP, Massidda M, Yilmaz O, Demiray-Gürbüz E, Manca A, Bassotti G. Miocamycin-containing triple therapy for H. pylori infection. Helicobacter 2013; 18:285-9. [PMID: 23489645 DOI: 10.1111/hel.12048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION In Northern Sardinia, one-week triple standard therapies containing a proton-pump inhibitor and two antibiotics for H. pylori infection have an average cure rate of 57% largely due to a high prevalence of antimicrobial resistance. The efficacy of miocamycin-containing treatment for 10 days was evaluated. MATERIALS AND METHODS Patients referred to the endoscopy service for dyspeptic symptoms were enrolled. H. pylori infection was defined as a positive rapid urease test, presence of the bacteria on gastric biopsies, and a positive 13C-UBT. Treatment consisted of 10 days with omeprazole 20 mg, miocamycin water-soluble 900 mg, and tinidazole 500 mg all bid. Success was evaluated 40-50 days after the end of therapy and defined by a negative 13C-UBT. Compliance was considered good if at least 90% of the total number of the pills were taken. Fluorescent in situ hybridization (FISH) technique was applied on paraffin-embedded gastric tissue sections to test susceptibility to clarithromycin of the bacteria. RESULTS 50 patients were enrolled (mean age; 52, 36% men). Miocamycin-containing therapy cured 86% (42/49; 95% CI = 72-94%) of infected patients by PP analysis. Susceptibility data (FISH) was available for 38 patients. Cure rates for the 28 with clarithromycin-susceptible infection was 96% vs 50% for those with resistant or mixed infection, (p = .003). Good compliance was recorded in 48 patients. None of the patients discontinued therapy. CONCLUSIONS Miocamycin appears to be a valid alternative for clarithromycin for H. pylori eradication. Head-to-head studies will be needed to ascertain whether it is superior.
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Affiliation(s)
- Maria Pina Dore
- Dipartimento di Medicina Clinica e Sperimentale, University of Sassari, Sassari, Italy.
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23
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Selgrad M, Bornschein J, Malfertheiner P. Guidelines for treatment of Helicobacter pylori in the East and West. Expert Rev Anti Infect Ther 2013; 9:581-8. [PMID: 21819326 DOI: 10.1586/eri.11.80] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Infection with Helicobacter pylori remains a major healthcare burden, with persistently high prevalence rates, especially in less-developed countries. H. pylori infection is causally related to non-malignant and malignant gastroduodenal diseases, such as peptic ulcer diseases, gastric cancer and gastric mucosa-associated lymphoid tissue lymphoma. Current international guidelines recommend a standard triple therapy as first-line therapy, including a proton pump inhibitor and a combination of amoxicillin and clarithromycin. Standard triple therapy has shown a decreasing efficacy over the years. The main reason is the increasing antibiotic resistance, particular to clarithromycin of H. pylori strains. Several new treatment options or modifications of already established regimens have been introduced to overcome treatment failure. In this article, we intend to report the reasons for treatment failure, and furthermore we give an overview of new treatment options as alternatives to the current treatment regimens. Finally, the strategy for the future is considered.
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Affiliation(s)
- Michael Selgrad
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke-University of Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany
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Seyedmajidi S, Mirsattari D, Zojaji H, Zanganeh E, Seyyedmajidi M, Almasi S, Zali M. Penbactam for Helicobacter pylori eradication: a randomised comparison of quadruple and triple treatment schedules in an Iranian population. Arab J Gastroenterol 2013; 14:1-5. [PMID: 23622801 DOI: 10.1016/j.ajg.2012.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 08/01/2012] [Accepted: 12/09/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND & STUDY AIMS Selection of the best drug regimens for eradication of Helicobacter pylori infection especially in patients at risk of peptic ulcer relapses and the development of complications is challenging. This study assessed and compared the efficacy of the two common PPI based triple therapies to a quadruple therapy including PPI, metronidazole, amoxicillin and a bismuth compound in Iranian population. PATIENTS & METHODS Three hundred and thirty patients with peptic ulcer and H. pylori infection were included in the study. Patients were randomly assigned to one of the three treatment protocols all given twice daily: (a) A 14-day quadruple therapy (OMAB group) comprising omeprazole 20mg, metronicazole 500 mg, amoxicillin 1g, and bismuth subcitrate 240 mg; (b) A 14-day triple regimen (OCP group) comprising omeprazole 20mg plus clarithromycine 500 mg and penbactam 750 mg and (c) A 14-day triple regimen (OCA group) comprising omeprazole 20mg plus clarithromycine 500 mg and amoxicillin 1g. Cure was defined as a negative urea breath test at least six weeks after treatment. RESULTS The per-protocol eradication rates achieved with both OCP regimen (87.0%) and OCA treatment (90.8%) were significantly higher than the OMAB treatment protocol (56.0%); however, no significant difference emerged in eradication rates between the two triple treatment schedules. No significant differences between the groups were found in most side-effects. CONCLUSION Two-week quadruple therapy showed a lower eradication rate compared to common triple treatment schedules when used as first-line eradication treatment for H. pylori infection in Iranian population.
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Affiliation(s)
- Seyedali Seyedmajidi
- Golestan Research Center of Gastroenterology & Hepatology, Department of Internal Medicine, Golestan University of Medical Sciences, Gorgan, Iran
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25
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Seyedmajidi S, Mirsattari D, Zojaji H, Zanganeh E, Seyyedmajidi M, Almasi S, Zali M. Penbactam for Helicobacter pylori eradication: a randomised comparison of quadruple and triple treatment schedules in an Iranian population. Arab J Gastroenterol 2013. [PMID: 23622801 DOI: 10.1016/j.ajg.2010.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND & STUDY AIMS Selection of the best drug regimens for eradication of Helicobacter pylori infection especially in patients at risk of peptic ulcer relapses and the development of complications is challenging. This study assessed and compared the efficacy of the two common PPI based triple therapies to a quadruple therapy including PPI, metronidazole, amoxicillin and a bismuth compound in Iranian population. PATIENTS & METHODS Three hundred and thirty patients with peptic ulcer and H. pylori infection were included in the study. Patients were randomly assigned to one of the three treatment protocols all given twice daily: (a) A 14-day quadruple therapy (OMAB group) comprising omeprazole 20mg, metronicazole 500 mg, amoxicillin 1g, and bismuth subcitrate 240 mg; (b) A 14-day triple regimen (OCP group) comprising omeprazole 20mg plus clarithromycine 500 mg and penbactam 750 mg and (c) A 14-day triple regimen (OCA group) comprising omeprazole 20mg plus clarithromycine 500 mg and amoxicillin 1g. Cure was defined as a negative urea breath test at least six weeks after treatment. RESULTS The per-protocol eradication rates achieved with both OCP regimen (87.0%) and OCA treatment (90.8%) were significantly higher than the OMAB treatment protocol (56.0%); however, no significant difference emerged in eradication rates between the two triple treatment schedules. No significant differences between the groups were found in most side-effects. CONCLUSION Two-week quadruple therapy showed a lower eradication rate compared to common triple treatment schedules when used as first-line eradication treatment for H. pylori infection in Iranian population.
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Affiliation(s)
- Seyedali Seyedmajidi
- Golestan Research Center of Gastroenterology & Hepatology, Department of Internal Medicine, Golestan University of Medical Sciences, Gorgan, Iran
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Efficacy of a "Rescue" Ciprofloxacin-Based Regimen for Eradication of Helicobacter pylori Infection after Treatment Failures. Gastroenterol Res Pract 2012; 2012:484591. [PMID: 22666234 PMCID: PMC3359787 DOI: 10.1155/2012/484591] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 03/10/2012] [Indexed: 02/07/2023] Open
Abstract
The aim of our study was to evaluate the efficacy and tolerability of a ciprofloxacin-based regimen for H. pylori eradication failures as an alternative to bismuth based quadruple therapy. Methods. Design: prospective single-center study. Patients in whom a first eradication trial with omeprazole/esomeprazole, clarithromycin plus amoxicillin or tinidazole/metronidazole had failed were included. H. pylori status: established by histology, rapide urease test and polymerase chain reaction. Intervention: esomeprazole 20 mg, ciprofloxacin 500 mg, and metronidazole 500 mg, administered together before breakfast and dinner for 10 days. Susceptibility testing was performed by the Epsilometer test. Ciprofloxacin resistance was defined as a MIC of ≥1 μg/mL. Eradication was established by a negative 13C-UBT and 4–6 weeks post-therapy. Efficacy and side effects were determined. Results. 34 patients were enrolled, 32 completed the study. Compliance was excellent (100%). Side effects were mild. Ciprofloxacin-based therapy cured 65% (22/34) of patients by intention to treat and 69% (22/32) per protocol analysis. The prevalence of ciprofloxacin resistance was 8%. Conclusions. The effectiveness of ciprofloxacin-based therapy was greatly reduced despite the high prevalence of ciprofloxacin sensitive H. pylori strains. Bismuth based quadruple therapy still remain the best choice as a “rescue” regimen in our region.
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Abstract
PURPOSE OF REVIEW The article will give an overview on reasons for treatment failure and tries to show new concepts for Helicobacter pylori treatment. RECENT FINDINGS Several new treatment options or modifications of already established regimens have been introduced to overcome treatment failure. Antibiotic resistance to H. pylori is the key factor for treatment failure. At the moment, standard triple therapy remains the primary choice in regions with proven low clarithromycin resistance rates. In areas with high clarithromycin resistance, four drug treatment regimens, including quadruple and sequential therapy, have proven the best results as first-line regimens. The options for second-line treatment regimens are manifold. Second-line treatment regimens need to be adapted accurately to local resistance rates. SUMMARY Treatment of H. pylori infection is challenged by a dramatic fall in eradication rates all over the world. Newer regimens have been introduced including sequential, quadruple therapies and those regimens provide promising results, but the knowledge about local resistance rates remains the key to an effective therapy.
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Lee SK, Lee SW, Park JY, Kwon BS, Kim SY, Hyun JJ, Kim JH, Jung SW, Koo JS, Yim HJ, Choi JH. Effectiveness and safety of repeated quadruple therapy in Helicobacter pylori infection after failure of second-line quadruple therapy: repeated quadruple therapy as a third-line therapy. Helicobacter 2011; 16:410-4. [PMID: 21923688 DOI: 10.1111/j.1523-5378.2011.00870.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUNDS Quadruple therapy using a proton-pump inhibitor, bismuth, metronidazole, and tetracycline is a standard second-line therapy for Helicobacter pylori infection, achieving an eradication rate of about 80% in Korea. A standard third-line therapy is not currently established, although various protocols have been proposed. We performed this study to evaluate the effectiveness of a retrial with quadruple therapy before starting a third-line treatment with new drugs. MATERIALS AND METHODS In 80 of 746 patients treated with a second-line quadruple therapy at the Korea University Ansan Hospital between January 2002 and September 2010, treatment for H. pylori had failed, and 45 of these patients were eligible for this study. Eradication of H. pylori was assessed by repeated endoscopy or by the (13) C-urea breath test at least 4 weeks after therapy. The patients with treatment failure were treated again with quadruple regimen for 2 weeks and reevaluated for treatment effectiveness and safety. RESULTS The eradication rate with second-line quadruple therapy was 86.9%. Of the 80 patients who failed treatment for H. pylori with the initial second-line quadruple therapy, 64 patients were treated again with the same regimen. Of the 45 retreated patients in this study, three patients were lost to follow-up and two complied poorly with medication. The eradication rate in the 40 patients retreated was 75.0% at per-protocol analysis. Seventeen patients experienced mild adverse events. CONCLUSIONS A retrial of quadruple therapy before use of a third-line therapy may be safe and effective for patients who fail to respond to second-line quadruple therapy.
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Affiliation(s)
- Sang Kyu Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Alkim H, Iscan M, Oz F. Effectiveness of ranitidine bismuth citrate and proton pump inhibitor based triple therapies of Helicobacter pylori in Turkey. Libyan J Med 2011; 6:LJM-6-8412. [PMID: 21912572 PMCID: PMC3171195 DOI: 10.3402/ljm.v6i0.8412] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 08/09/2011] [Indexed: 12/15/2022] Open
Abstract
Background Helicobacter pylori infection is the main cause of gastritis, gastroduodenal ulcer disease, MALT lymphoma, and adenocarcinoma of the stomach. The reported prevalence of H. pylori in the adult population in Turkey is 67.6%–81.3%. A national meta-analysis showed that the average H. pylori eradication rate with proton pump inhibitor-based triple regimens in Turkey had decreased from 84% in 1997 to 55.3% in 2004, suggesting a need to evaluate alternative regimens. Materials and methods The study was a prospective, single-center trial with a parallel group design. After the selection procedure, consecutive out-patients were assigned to one of six study groups using random sampling numbers. All patients received amoxicillin 1,000 mg b.i.d. and clarithromycin 500 mg b.i.d. along with ranitidine bismuth citrate 400 mg b.i.d., or omeprazole 20 mg b.i.d., or lansoprazole 30 mg b.i.d., or rabeprazole 20 mg b.i.d., or pantoprazole 40 mg b.i.d., or esomeprazole 40 mg b.i.d. for 14 days. Results When we look at the eradication rates of the treatment groups, only two groups (ranitidine bismuth citrate and rabeprazole groups) had eradication rates greater than 80%, both at intention to treat and per protocol analyses. The other four groups (omeprazole, lansoprazole, pantoprazole, and esomeprazole groups) showed statistically significant lower eradication rates both at intention to treat (between 57.6 and 66.7%) and per protocol (between 60.3 and 72.1%) analyses when compared with ranitidine bismuth citrate and rabeprazole groups (p<.05). Conclusion Ranitidine bismuth citrate and/or rabeprazole based triple therapies must be preferred for the first-line treatment of H. pylori infection.
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Affiliation(s)
- Huseyin Alkim
- Department of Gastroenterology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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30
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Dore MP, Farina V, Cuccu M, Mameli L, Massarelli G, Graham DY. Twice-a-day bismuth-containing quadruple therapy for Helicobacter pylori eradication: a randomized trial of 10 and 14 days. Helicobacter 2011; 16:295-300. [PMID: 21762269 DOI: 10.1111/j.1523-5378.2011.00857.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Bismuth-containing quadruple therapy given twice a day for 14 days has been shown to be an excellent first-line H. pylori eradication therapy. AIM To compare the efficacy and tolerability of twice-a-day bismuth-containing quadruple H. pylori eradication therapy for 10 versus 14 days in a noninferiority trial. METHODS Dyspeptic patients with H. pylori infection and naïve to H. pylori treatment were randomly assigned to: pantoprazole 20 mg, tetracycline 500 mg, metronidazole 500 mg, and bismuth subcitrate caplets 240 mg given b.i.d. (with the midday and evening meals) for 10 or 14 days. Eradication was defined by negative UBT and/or histology 4-6 weeks posttherapy. Efficacy and side effects were determined. RESULTS A total of 417 patients were randomized (153 men, 264 women; median age 52). Per protocol (PP) treatment success with 14 and 10 days was essentially identical [i.e., 96% (95% CI: 92-98) vs 95% (95% CI: 91-98) for 14 days versus 10 days, respectively. Results with intention-to-treat (ITT) analysis were also similar (92% (95% CI, 87-95) vs 92% (95% CI, 88-96)) for 14 and 10 days, respectively. Compliance was excellent in both groups. Side effects were generally mild and similar between groups. Fatigue, discomfort, and vomiting were more common in those in the 14-day group. The 10-day regimen costs € 17.65 (ie, approximately 25%) less than the 14-day regimen. CONCLUSIONS Bismuth-containing quadruple therapy remained highly effective (i.e., ≥95% PP and >90% ITT) despite reducing the duration from 14 to 10 days.
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Affiliation(s)
- Maria Pina Dore
- Istituto di Clinica Medica, University of Sassari, Viale San Pietro 8, 07100 Sassari, Italy.
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Bohr URM, Malfertheiner P. Eradication of H. pylori Infection: the Challenge is on if Standard Therapy Fails. Therap Adv Gastroenterol 2011; 2:59-66. [PMID: 21180534 DOI: 10.1177/1756283x08100352] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The recommended standard triple therapy for Helicobacter pylori infection, consisting of a proton pump inhibitor, clarithromycin and amoxicillin or metronidazole, can reach eradication rates in over 90%. However, in recent years resistance to antibiotics has increased and eradication rates have declined. Approximately one in five patients need a second-line therapy because eradication therapy fails. Second-line treatment with a bismuth-based quadruple therapy leads to satisfactory eradication rates, but bismuth is not available in many countries. Modern second- and third-line treatments can only be successful if they are adapted to the current resistance situation and they need to evolve continuously. Moreover, pharmacodynamic effects due to polymorphisms of the cytochrome P450 system are important. Because therapy adherence is significantly associated with therapy success, modern regimens if possible should be easy to take and well tolerated. In recent years, various novel salvage-therapy regimens have been investigated that significantly improve treatment options.
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Affiliation(s)
- Ulrich R M Bohr
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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Abstract
It is accepted that the success of Helicobacter pylori eradication treatment using standard triple therapy is declining. Resistance, particularly to clarithromycin, has been shown in numerous countries to be rising to a level where the use of standard triple therapy in its current form may no longer be justified. The two major factors influencing resistance are prior exposure to the antibiotic and compliance with therapy. Regimes based on bismuth and levofloxacin, which had previously been mainly second-line options, are now emerging as superior first-line options. Trials of sequential and concomitant therapies are also showing the usefulness of these treatments in different populations. Options for third and subsequent line therapies include furazolidone and rifabutin-based regimes. Susceptibility testing should be performed to maintain accurate data on resistance levels, and has also clinical utility in difficult to eradicate cases. None of these, however, will be successful unless compliance is improved upon. If compliance is assured and eradication confirmation pursued, it has been repeatedly illustrated that near full eradication is achievable.
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Affiliation(s)
- Anthony O'Connor
- Department of Gastroenterology, Adelaide and Meath Hospital incorporating the National Children's Hospital/Trinity College Dublin, Tallaght, Dublin 24, Ireland.
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Bismuth-doped injectable calcium phosphate cement with improved radiopacity and potent antimicrobial activity for root canal filling. Acta Biomater 2010; 6:3199-207. [PMID: 20197122 DOI: 10.1016/j.actbio.2010.02.049] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 02/21/2010] [Accepted: 02/24/2010] [Indexed: 12/30/2022]
Abstract
A bismuth-doped injectable calcium phosphate cement (BD-ICPC) with improved radiopacity, potent antimicrobial activity and sealability was developed by introducing bismuth salicylate basic (BSB) into the powder phase of the calcium phosphate cement (CPC). The results showed that the radiopacity and sealability of BD-ICPC were improved compared with pure ICPC. Although BSB had a retarding effect on the setting rate of the cement, the addition of BSB reduced the viscosity and yield stress of BD-ICPC, thus enhanced its injectability. It was noteworthy that BD-ICPC had a potent antimicrobial activity with improved sealability. In addition, BD-ICPC afforded a uniform and tight adaptation to the root canal wall. These results indicate that BD-ICPC possesses a combination of good in vitro radiopacity, high injectability, potent antimicrobial activity, improved sealability and tight adaptation to the root canal. It is expected to be used as a novel root canal filling material.
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Saleem A, Qasim A, O'Connor HJ, O'Morain CA. Pylera for the eradication of Helicobacter pylori infection. Expert Rev Anti Infect Ther 2009; 7:793-9. [PMID: 19735221 DOI: 10.1586/eri.09.55] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
An ideal antibiotic regimen for Helicobacter pylori should achieve eradication rates of approximately 90%. Current 7-day triple therapy is successful in about two-thirds of patients. A novel treatment is required to achieve higher eradication with minimal induction of bacterial resistance. The aim of this article is to evaluate the safety and efficacy of a single triple capsule (Pylera) containing bismuth, metronidazole and tetracycline, given with omeprazole for the eradication of H. pylori infection. Extensive literature searches were conducted using PubMed data from 1982 to 2007. This search included headings of H. pylori, bismuth and eradication therapy. The triple capsule Pylera, when given with omeprazole, achieved eradication rates ranging between 84 and 97%. Eradication rates were similar for clarithromycin- and metronidazole-resistant strains. Eradication rates with an omeprazole, bismuth, metronidazole and tetracycline regimen appeared comparable for metronidazole-resistant and -sensitive strains. This effect is not seen with the use of triple therapy in cases of clarithromycin resistance. Clinical trials did not report any serious side effects from bismuth-based regimens and compliance was similar to standard triple therapy. Bismuth-based triple therapy using Pylera is a simplified, effective and well-tolerated regimen achieving cure rates of above 90%.
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Affiliation(s)
- Aamir Saleem
- Adelaide and Meath Hospital, Incorporating the National Children's Hospital, Tallaght, Trinity College Dublin, Ireland.
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Fock KM, Katelaris P, Sugano K, Ang TL, Hunt R, Talley NJ, Lam SK, Xiao SD, Tan HJ, Wu CY, Jung HC, Hoang BH, Kachintorn U, Goh KL, Chiba T, Rani AA. Second Asia-Pacific Consensus Guidelines for Helicobacter pylori infection. J Gastroenterol Hepatol 2009; 24:1587-600. [PMID: 19788600 DOI: 10.1111/j.1440-1746.2009.05982.x] [Citation(s) in RCA: 408] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The Asia-Pacific Consensus Conference was convened to review and synthesize the most current information on Helicobacter pylori management so as to update the previously published regional guidelines. The group recognized that in addition to long-established indications, such as peptic ulcer disease, early mucosa-associated lymphoid tissue (MALT) type lymphoma and family history of gastric cancer, H. pylori eradication was also indicated for H. pylori infected patients with functional dyspepsia, in those receiving long-term maintenance proton pump inhibitor (PPI) for gastroesophageal reflux disease, and in cases of unexplained iron deficiency anemia or idiopathic thrombocytopenic purpura. In addition, a population 'test and treat' strategy for H. pylori infection in communities with high incidence of gastric cancer was considered to be an effective strategy for gastric cancer prevention. It was recommended that H. pylori infection should be tested for and eradicated prior to long-term aspirin or non-steroidal anti-inflammatory drug therapy in patients at high risk for ulcers and ulcer-related complications. In Asia, the currently recommended first-line therapy for H. pylori infection is PPI-based triple therapy with amoxicillin/metronidazole and clarithromycin for 7 days, while bismuth-based quadruple therapy is an effective alternative. There appears to be an increasing rate of resistance to clarithromycin and metronidazole in parts of Asia, leading to reduced efficacy of PPI-based triple therapy. There are insufficient data to recommend sequential therapy as an alternative first-line therapy in Asia. Salvage therapies that can be used include: (i) standard triple therapy that has not been previously used; (ii) bismuth-based quadruple therapy; (iii) levofloxacin-based triple therapy; and (iv) rifabutin-based triple therapy. Both CYP2C19 genetic polymorphisms and cigarette smoking can influence future H. pylori eradication rates.
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Affiliation(s)
- K Ming Fock
- Division of Gastroenterology, Department of Medicine, Changi General Hospital, Singapore 529889.
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Abstract
This article aims to examine current best practice in the field reference to first-line, second-line, rescue and emerging treatment regimens for Helicobacter pylori eradication. The recommended first-line treatment in published guidelines in Europe and North American is proton pump inhibitor combined with amoxicillin and clarithromycin being the favoured regimen. Rates of eradication with this regimen however are falling alarmingly due to a combination of antibiotic resistance and poor compliance with therapy. Bismuth based quadruple therapies and levofloxacin based regimes have been shown to be effective second line regimens. Third-line options include regimes based on rifabutin or furazolidone, but susceptibility testing is the most rational option here, but is currently not used widely enough. Sequential therapy is promising but needs further study and validation outside of Italy. Although the success of first line treatments is falling, if compliance is good and a clear treatment paradigm adhered to, almost universal eradication rates can still be achieved. If compliance is not achievable, the problem of antibiotic resistance will continue to beset any combination of drugs used for H. pylori eradication.
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Affiliation(s)
- Anthony O'Connor
- Department of Gastroenterology, Adelaide and Meath Hospital incorporating the National Children's Hospital Tallaght, Trinity College Dublin, Dublin, Ireland
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37
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Severi C, Abdullahi M, Tari R, Vannella L, Marcheggiano A, Capoccia D, Leonetti F, Osborn J, Annibale B. High efficacy of bismuth subcitrate for Helicobacter pylori eradication in pangastritis. Dig Liver Dis 2009; 41:555-8. [PMID: 19179127 DOI: 10.1016/j.dld.2008.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Revised: 10/04/2008] [Accepted: 11/13/2008] [Indexed: 02/05/2023]
Abstract
BACKGROUND The influence of gastritis patterns in Helicobacter pylori eradication rates has been poorly investigated. AIMS To compare the efficacy of bismuth or proton pump inhibitors triple therapy for H. pylori eradication in pangastritis. PATIENTS AND METHODS One hundred and eight patients with pangastritis were assigned to either lansoprazole 30 mg once a day (n=54) or bismuth 240 mg bis in die (n=54) for 14 days combined, for the first week, with amoxicillin 1g plus metronidazole 250 mg tris in die. Eradication was confirmed by (13)C-urea breath test. RESULTS With bismuth, successful eradication was observed in 75.9% (41/54) in the intention-to-treat analysis and 78.8% (41/52) in the per-protocol analysis. With lansoprazole, the eradication rates were respectively 46.3% (25/54) and 51.0% (25/49). Bismuth had a significant higher efficacy according to both intention-to-treat analysis (p=0.0029) and per-protocol analysis (p=0.0038) with OR of 3.66 (95% CI: 1.61-8.32) and 3.58 (95% CI: 1.50-8.54) respectively. At regression analysis, the only independent variable affecting eradication was the type of regimen (p=0.026) with an OR of 3.31 (95% CI: 1.16-9.44). CONCLUSIONS In pangastritis patients, bismuth is more effective than PPI in first-line eradication. For improving the overall eradication rates, an evaluation of gastritis extent might need to be considered.
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Affiliation(s)
- C Severi
- Gastroenterology Unit, Department of Clinical Sciences, University La Sapienza, Rome, Italy.
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Dore MP, Sepulveda AR, Pedroni A, Realdi G, Delitala G. Reversal of elevated pancreatic enzymes after Helicobacter pylori eradication. Intern Emerg Med 2008; 3:269-70. [PMID: 18264669 DOI: 10.1007/s11739-008-0117-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Accepted: 05/09/2007] [Indexed: 02/07/2023]
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Abstract
Helicobacter pylori is one of the most common bacterial infections in the world. H pylori infection of the gastric mucosa is the most common cause of peptic ulcers and is believed to be responsible for 50% to 60% of all gastric carcinomas. This infection is difficult to treat because the bacterium is located within the gastric lumen in the mucus and not within the gastric tissue. Antimicrobial therapy for H pylori includes two or three antibiotics plus either a proton pump inhibitor or a histamine receptor antagonist. H pylori readily develops resistance to antibiotics; therefore, if the initial treatment is unsuccessful, repeat treatment should include different antibiotics.
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Affiliation(s)
- Jason Collins
- Gastroenterology Section, Department of Medicine, Howard University College of Medicine, Washington, DC 20059, USA
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Duckworth M, Ménard A, Megraud F, Mendz GL. Bioinformatic analysis of Helicobacter pylori XGPRTase: a potential therapeutic target. Helicobacter 2006; 11:287-95. [PMID: 16882332 DOI: 10.1111/j.1523-5378.2006.00409.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Xanthine-guanine phosphoribosyltransferase (XGPRTase) is an enzyme of purine nucleotide salvage synthesis. The gpt gene of Helicobacter pylori has been annotated as encoding an XGPRTase and proposed as essential for survival of the bacterium in vitro. The aims of this work were to investigate the structure of H. pylori XGPRTase and to compare the key features of the enzyme to other phosphoribosyltransferases employing computational, modelling, and bioinformatic tools. MATERIALS AND METHODS XGPRTase activity was measured in the cytosolic fraction of H. pylori by (31)P-nuclear magnetic resonance spectroscopy, and also in recombinant XGPRTase produced by a cell-free expression system. Bioinformatics was employed to analyze the phylogeny of XGPRTase, and a structural model of the XGPRTase was built using threading techniques. The observed interactions of purine phosphoribosyltransferases with immucillin-GP were used to study the theoretical interactions of H. pylori XGPRTase with this transition-state analog. RESULTS It was demonstrated that the gpt gene of H. pylori encodes a functional XGPRTase enzyme. Analyses of the XGPRTase sequence showed that the enzyme is significantly divergent from equivalent mammalian enzymes. Modelling served to identify specific features of the enzyme and key residues involved in catalysis. CONCLUSIONS The H. pylori XGPRTase is structurally similar to other phosphoribosyltransferase enzymes, but there were significant differences between the hood domain of H. pylori XGPRTase and other purine salvage phosphoribosyltransferases. Significant differences were found between the interactions of the H. pylori and human enzymes with a purine phosphoribosyltransferase inhibitor.
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Affiliation(s)
- Megan Duckworth
- School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, New South Wales, Australia
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Dore MP, Maragkoudakis E, Pironti A, Tadeu V, Tedde R, Realdi G, Delitala G. Twice-a-day quadruple therapy for eradication of Helicobacter pylori in the elderly. Helicobacter 2006; 11:52-5. [PMID: 16423090 DOI: 10.1111/j.0083-8703.2006.00370.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Midday and evening twice-a-day quadruple therapy appears to be the most effective therapy for Helicobacter pylori infection in Northern Sardinia, a site where antibiotics resistance is common. AIM The objective of our study was to estimate the efficacy, side-effects, and compliance of a quadruple therapy containing esomeprazole in a group of dyspeptic elderly patients. PATIENTS AND METHODS Consecutive elderly patients positive for H. pylori infection and not previously treated for eradication were enrolled. Therapy consisted of esomeprazole 20 mg, tetracycline 500 mg, metronidazole 500 mg, and bismuth subcitrate tablets 240 mg, all twice-a-day with the midday and evening meals, for 10 days. Efficacy was evaluated using 13C-urea breath testing. Compliance was assessed after completing treatment and at follow up. Side effects were graded based on daily activities. RESULTS Ninety-five dyspeptic patients (range 65-81 years), 52 men and 43 women, were enrolled. The intention-to-treat cure rate was 91% (81 of 89; 95% CI = 88-99%) and, 95% (81 of 85; 95% CI = 83-96%) per-protocol analysis. Compliance was excellent. Mild-moderate side effects occurred in 27 patients. CONCLUSIONS Esomeprazole containing quadruple therapy was highly successful for initial eradication of H. pylori in elderly patients.
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Affiliation(s)
- Maria Pina Dore
- Istituto di Clinica Medica, Università degli Studi di Sassari, Italy.
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Stabile BE, Smith BR, Weeks DL. Helicobacter pylori infection and surgical disease---part I. Curr Probl Surg 2006; 42:756-89. [PMID: 16310017 DOI: 10.1067/j.cpsurg.2005.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Pohl H, Finlayson SRG, Sonnenberg A, Robertson DJ. Helicobacter pylori-associated ulcer bleeding: should we test for eradication after treatment? Aliment Pharmacol Ther 2005; 22:529-37. [PMID: 16167969 DOI: 10.1111/j.1365-2036.2005.02569.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Eradication of Helicobacter pylori after peptic ulcer haemorrhage reduces the risk of recurrence. Because H. pylori treatment is very effective, it is unclear whether testing to confirm eradication is worthwhile. AIMS To examine whether patients with H. pylori-associated peptic ulcer haemorrhage should be tested for successful eradication after completion of antibiotic therapy. METHODS A Markov cost-effectiveness model was developed to compare testing vs. non-testing of H. pylori eradication in peptic ulcer haemorrhage. Probability estimates and average costs were derived from published information. RESULTS Testing for H. pylori eradication resulted in a benefit of 0.07 quality-adjusted life-years and cost 836 US dollars less than the strategy of not confirming eradication. Testing remained the superior strategy when varying the model regarding age, the initial success of eradication, various test and retreatment strategies, and the rate and costs of recurrent bleeding. Assuming a high eradication rate (95%), the test strategy becomes more expensive only if the cost of H. pylori testing reaches 265 US dollars; however, even under these conditions it remains cost-effective. CONCLUSIONS Patients with H. pylori-associated peptic ulcer bleeding should be tested to confirm eradiation of H. pylori after completion of antibiotic treatment.
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Affiliation(s)
- H Pohl
- VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT, USA.
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Iacopini F, Crispino P, Paoluzi OA, Consolazio A, Pica R, Rivera M, Palladini D, Nardi F, Paoluzi P. One-week once-daily triple therapy with esomeprazole, levofloxacin and azithromycin compared to a standard therapy for Helicobacter pylori eradication. Dig Liver Dis 2005; 37:571-6. [PMID: 15996628 DOI: 10.1016/j.dld.2005.03.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2004] [Accepted: 03/04/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND Primary antibiotic-resistance and poor compliance are the main causes of Helicobacter pylori eradication failure of standard regimens. AIM To investigate eradication rate, patient compliance and tolerability of a 1-week once-daily levofloxacin plus azithromycin triple therapy versus the standard twice-daily triple therapy. PATIENTS AND METHODS A total of 164 H. pylori-positive patients were randomised to either esomeprazole 20mg, levofloxacin 500 mg and azithromycin 500 mg once-daily (ELAz) or esomeprazole 20mg, clarithromycin 500 mg and amoxycillin 1g twice-daily (ECA) for 1 week. H. pylori infection was defined at entry by histology and urea breath test; cure of infection was determined both by negative urea breath test and H. pylori stool antigens. RESULTS H. pylori eradication rates of ELAz and ECA were similar at intention-to-treat (both 65%) and per-protocol analyses (70% versus 76%, respectively). Incidence of poor compliance was lower, although not significantly, in patients randomised to ELAz than to ECA (4% versus 10%); tolerability was significantly higher for ELAz than for ECA (88% versus 70%; P=0.01). CONCLUSIONS Once-daily levofloxacin plus azithromycin-based triple therapy achieves an H. pylori eradication rate comparable to that of standard twice-daily triple therapy, but is associated with higher patient compliance and might even be better tolerated.
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Affiliation(s)
- F Iacopini
- Gastroenterology Unit, Department of Clinical Sciences, University 'La Sapienza', Rome, Italy
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Graham DY, Opekun AR, Belson G, El-Zimaity HMT, Carlson MR. Novel bismuth-metronidazole-tetracycline triple-layer tablet for treatment of Helicobacter pylori. Aliment Pharmacol Ther 2005; 21:165-8. [PMID: 15679766 DOI: 10.1111/j.1365-2036.2005.02322.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Current anti-Helicobacter pylori treatment regimens are costly and because of the increasing antibiotic resistance, are becoming ineffective. AIM To evaluate a triple-layer tablet containing 100 mg bismuth subcitrate, 250 mg metronidazole, and 250 mg tetracycline in a single triple-layer tablet. METHODS H. pylori-infected adult patients received bismuth-metronidazole-tetracycline (two tablets, t.d.s.) and ranitidine (300 mg) once daily for 14 days. Efficacy was determined using 13C-urea breath testing. RESULTS Thirty-three of 35 enrolled patients were available for evaluation; using the protocol-specified modified intention-to-treat analysis, five failed treatment, two were lost to follow-up (cure rate per-protocol = 85.7%, intention-to-treat = 78.7%). The cure rate among metronidazole-susceptible strains was 100% (22 of 22) (95% confidence interval 84-100%) compared with 55% (five of nine intention-to-treat) (95% confidence interval 21-86%) among metronidazole-resistant strains. In four cases, therapy was truncated at 4-7 days because of side-effects; yet the treatment was effective in three. The three metronidazole-susceptible but clarithromycin-resistant infections were cured. CONCLUSION This novel triple-layer tablet combination therapy was effective in all patients with metronidazole-susceptible H. pylori and many of those with resistant organisms. A greater degree of acid suppression may further improve effectiveness.
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Affiliation(s)
- D Y Graham
- Department of Medicine, VA Medical Center and Baylor College of Medicine, Houston, TX 77030, USA.
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Wu Y, Fassihi R. Stability of metronidazole, tetracycline HCl and famotidine alone and in combination. Int J Pharm 2005; 290:1-13. [PMID: 15664125 DOI: 10.1016/j.ijpharm.2004.10.015] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2004] [Revised: 10/22/2004] [Accepted: 10/22/2004] [Indexed: 12/30/2022]
Abstract
Metronidazole, tetracycline HCl and famotidine are commonly used for the treatment of Helicobacter pylori-associated peptic ulcer. In this paper, stabilities of these drugs and their combinations in solid and liquid states were studied as part of preformulation in the development of a combination drug delivery system. Solubility studies of metronidazole and tetracycline HCl were investigated, which indicated that both metronidazole and tetracycline HCl have high solubilities at and around pH 2.0. Metronidazole is relatively stable with little degradation in liquid phase. Tetracycline HCl in the dry state is stable when stored at room temperature regardless of exposure to light or humidity in the range of 20-65%. Enhanced temperature associated humidity effect was responsible for the instabilities of tetracycline HCl and famotidine to different extents. Elevated temperature accelerated the degradation of all the drugs in liquid phase but light exposure was not a factor for the degradation. The degradation processes of tetracycline HCl and famotidine were highly dependent on the pH of the solution, and relatively stable profiles were achieved at pH 4.0. No potential incompatibility between the drugs under storage conditions was observed in the development of a new multi-drug delivery tablet.
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Affiliation(s)
- Yunqi Wu
- Product Development, Scolr Pharma, Inc., Bellevue, Washington, USA
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Qasim A, Sebastian S, Thornton O, Dobson M, McLoughlin R, Buckley M, O'Connor H, O'Morain C. Rifabutin- and furazolidone-based Helicobacter pylori eradication therapies after failure of standard first- and second-line eradication attempts in dyspepsia patients. Aliment Pharmacol Ther 2005; 21:91-6. [PMID: 15644050 DOI: 10.1111/j.1365-2036.2004.02210.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Optimal management approach is not well defined for subjects who fail initial first- and second-line Helicobacter pylori eradication attempts and are dealt on a case-by-case basis by the specialists. AIM To evaluate the efficacy and safety of standard and 'rescue' eradication therapies at primary and secondary care levels. METHODS H. pylori infected dyspepsia patients referred to our C13 urea breath testing laboratory between January 1999 to February 2002 were included. Eradication failure at secondary care level was treated using strategies including antibiotic sensitivity testing and the use of rifabutin- and furazolidone-based therapies. RESULTS 3280 patients received standard first-line eradication therapy, which was successful in 2530 (77%) patients. Second-line therapy (bismuth-based 'quadruple') or triple therapy (altering constituent antibiotics) was successful in 56% of 270 treated patients. Subsequent eradication attempts using rifabutin-based (n = 34) and furazolidone-based (n = 10) regimens were successful in 38% and 60% patients respectively. H. pylori eradication rates were significantly different for guidelines compliant (94.8%) and non-compliant (82%) groups (P = 0.0001). H. pylori eradication rates for non-ulcer dyspepsia (40%) and peptic ulcer disease (36%) were not significantly different. CONCLUSIONS Available H. pylori eradication therapies remain very effective and compliance to guidelines achieves high success rates. Furazolidone-based 'rescue' regimen achieved high eradication rates after failure of the standard first-line, second-line and rifabutin-based therapies.
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Affiliation(s)
- Asghar Qasim
- Gastroenterology Department, Adelaide and Meath Hospital, Tallaght, Dublin, Ireland
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Fischbach LA, van Zanten S, Dickason J. Meta-analysis: the efficacy, adverse events, and adherence related to first-line anti-Helicobacter pylori quadruple therapies. Aliment Pharmacol Ther 2004; 20:1071-82. [PMID: 15569109 DOI: 10.1111/j.1365-2036.2004.02248.x] [Citation(s) in RCA: 141] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Owing to rising drug-resistant Helicobacter pylori infections, currently recommended proton-pump inhibitor-based triple therapies are losing their efficacy, and regimens efficacious in the presence of drug resistance are needed. AIMS To summarize the efficacy, safety and adherence of first-line quadruple H. pylori therapies in adults. METHODS Meta-regression models identified factors explaining variation in the efficacy of first-line quadruple therapies from 145 treatment arms. Estimates of average efficacy were calculated within homogeneous groups. RESULTS Quadruple therapy containing a gastric acid inhibitor, bismuth, metronidazole and tetracycline was enhanced when omeprazole was included, treatment duration lasted 10-14 days, and when therapy took place in the Netherlands, Hong Kong and Australia. Treatment efficacy decreased as the prevalence of metronidazole resistance increased. Even in areas with a high prevalence of metronidazole resistance, this quadruple regimen eradicated more than 85% of H. pylori infections when it contained omeprazole and was given for 10-14 days. Furthermore, in the presence of clarithromycin resistance, this quadruple regimen eradicated 90-100% of H. pylori infections, while the currently recommended triple therapy containing clarithromycin, amoxicillin and a proton-pump inhibitor eradicated only 25-61% (P < 0.001). Adherence and adverse events for quadruple therapy were similar to currently recommended triple therapies. CONCLUSIONS Guidelines should include quadruple therapy with a proton-pump inhibitor, a bismuth compound, metronidazole and tetracycline among recommended first-line anti-H. pylori therapies.
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Affiliation(s)
- L A Fischbach
- School of Public Health, University of Texas, Dallas Regional Campus, Dallas, TX, USA.
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Abstract
Review of the recently published data on Helicobacter pylori management highlights various interesting aspects. Current H. pylori eradication guidelines generally suggest a noninvasive 'test and treat' strategy for all dyspeptic patients with certain age limits depending on the local gastric neoplasia risk. According to the 'Maastricht 2-2000 Consensus Report' treatment should be thought of as a 'package' considering first- and second-line eradication therapies together. Various centres have published their results using novel antimicrobial formulations and 'rescue' and 'sequential' therapies. Review suggests that care at the specialist level remains a challenge and guidelines are deficient particularly as regards the selection and duration of eradication therapies. Results indicate that differences for CYP2C19 genotype and the selection of proton pump inhibitors have no significant role in determining eradication rates whereas antibiotic resistance and socio-economic factors play a variable role according to different geographical areas. Compliance remains an important factor in determining clinical outcome at the primary and secondary levels worldwide.
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Affiliation(s)
- Francesco Perri
- Department of Internal Medicine, 'Casa Sollievo della Sofferenza' IRCCS, San Giovanni Rotondo, Italy.
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Dore MP, Marras L, Maragkoudakis E, Nieddu S, Manca A, Graham DY, Realdi G. Salvage therapy after two or more prior Helicobacter pylori treatment failures: the super salvage regimen. Helicobacter 2003; 8:307-9. [PMID: 12950603 DOI: 10.1046/j.1523-5378.2003.00150.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although effective therapies are available for curing Helicobacter pylori infection, the problem persists about what to do for patients who fail two or more treatment courses despite a good compliance. AIM To test a twice a day midday quadruple therapy as salvage therapy. METHODS Dyspeptic H. pylori-infected patients who failed two or more courses of anti-H. pylori therapy received omeprazole 20 mg, tetracycline 500 mg, metronidazole 500 mg, and bismuth subcitrate caplets 240 mg twice a day (with the midday and evening meals) for 14 days. H. pylori status was evaluated by 13C-urea breath test and histology 4-6 weeks after therapy. Eradication was defined as no positive test. RESULTS Seventy-one patients were enrolled and 68 completed the full 14 days of therapy (mean age 46 years; 28 men). Thirty-three patients had failed prior treatment twice, 19 had failed three times, and 16 had failed four or more times. The cure rates were: intention to treat=93% (66/71); (95% CI=84% to 98%), per protocol=97% (66/68); (95% CI=89%- 100%). Success was excellent irrespective of diagnosis, age, prior treatment protocols, or smoking status. Moderate side-effects were experienced by only two patients. CONCLUSION Midday bismuth subcitrate based twice a day quadruple therapy was an excellent salvage therapy. BID midday quadruple regimen should be considered as the therapy of choice.
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Affiliation(s)
- Maria Pina Dore
- Institute of Internal Medicine, University of Medicine, Sassari, Italy
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