Levofloxacin-based triple therapy in first-line treatment for Helicobacter pylori eradication

Levofloxacin versus clarithromycin for Helicobacter pylori eradication: are 14 day regimens better than 10 day regimens?

Background

Helicobacter pylori eradication by the conventional clarithromycin therapy has largely dropped in the recent years possibly due to antimicrobial resistance. Hence, levofloxacin-based regimen has been used as salvage therapy. However, data regarding its effectiveness on eradication are controversial. This study aimed to compare the eradication rate of levofloxacin-based regiment to that of the conventional first-line clarithromycin regimen.

Methods

Patients diagnosed with H. pylori infection and treated with levofloxacin triple therapy or clarithromycin-based regimen for 10 or 14 days were included. Patients were excluded if they used antibiotics or proton pump inhibitors within 4 or 2 weeks, respectively, of the H. pylori eradication confirmation test. H. pylori eradication rate was assessed, as well as the impact of diabetes and esophagogastroduodenoscopy (EGD) findings.

Results

Of 245 patients, 145 were in the levofloxacin group and 100 in the clarithromycin group. Most patients in either group received therapy for 14 days vs. 10 days (P = 0.002). Levofloxacin-based treatment was associated with a higher eradication rate compared with clarithromycin-based treatment (74.5 vs. 62%, respectively; P = 0.04). The 14 day levofloxacin-based regimen resulted in the highest eradication rate, followed by the 14 day regimen of clarithromycin (80.9 vs. 66.3%; P = 0.03). The 10 day regimens exhibited 62.7 and 41.2% eradication rates, respectively (P = 0.12). H. pylori eradication was not affected by diabetes or EGD findings (P = 0.98 and 0.3, respectively).

Conclusions

Results from this study support the use of a levofloxacin-based regimen as a first-line therapy in the treatment of H. pylori infection for 14 days regardless of diabetes and EGD findings.

First-line therapies for H. pylori infection in Italy: a pooled-data analysis

Background: Curing H. pylori infection remains challenging, and the use of most effective first-line therapy represents a therapeutic cornerstone. To monitor the efficacy of first-line therapies in Italy, we designed a systematic review with pooled- data analysis of data published in the last 15 years. Methods: The search was focused on standard regimens and adult patients. Studies that included modified therapy regimens, pediatric patients, case series with less than 5 patients, and those in language other than English were excluded. Results: A total of 40 studies, with 74 therapeutic arms and 13,539 patients were evaluated. Among the 14-day triple therapies, the combination with proton pump inhibitor (PPI), clarithromycin and amoxicillin achieved the highest (77.9%) success rate, whilst the lowest success rate (62.7%) was observed following the 14-day PPI, clarithromycin and tinidazole regimen. The overall efficacy of triple therapies significantly decreased from 75.7% to 72.1% in the last decade. Sequential (88.3% on 3431 patients), concomitant (88.8% on 376 patients), and the bismuth-based quadruple therapy with three-in-one capsule, containing bismuth subcitrate potassium (140 mg), metronidazole (125 mg), tetracycline (125 mg) (90.4% on 999 patients) achieved similarly high eradication rates, but data on concomitant are still limited. The bismuth-based was associated with the higher (38.7%) incidence of side-effects. Conclusions: Data found that all triple therapies, irrespective of drug combination and therapy duration, should be abandoned in Italy due to their unacceptable low success rates. Monitoring the efficacy of standard first-line therapies in other countries could be clinically useful for both patients and clinicians.

Multicenter Evaluation of a Gradient Diffusion Method for Antimicrobial Susceptibility Testing of Helicobacter pylori

Helicobacter pylori is an important human pathogen associated with peptic ulcer disease, dyspepsia, and gastric malignancy. Antimicrobial susceptibility testing (AST) is often requested for patients who fail eradication therapy. The Clinical and Laboratory Standards Institute (CLSI) reference method, agar dilution (AD), is not performed in most laboratories and maintaining organism viability during transit to a reference laboratory is difficult. We assessed the performance of the Etest (bioMérieux) as a method for H. pylori AST in comparison to AD. Etest MICs were determined for 83 H. pylori isolates at ARUP and Cleveland Clinic (CC). Categorical agreement (CA), very major, major, and minor errors (VME, ME, and mE) were determined for Etest using AD performed at Mayo Clinic Laboratories as the reference method. Testing on isolates with errors was repeated to determine final results summarized below. For clarithromycin, 66.3% of isolates were resistant (R) by AD; Etest results at each laboratory showed 1mE (1.2%) and 1 ME (3.8%). For tetracycline, only 2 isolates were R by AD; a single VME occurred at both sites (98.8% CA, 50% VME) with the same isolate. Applying EUCAST levofloxacin breakpoints to interpret ciprofloxacin results, 60.2% of isolates were R by AD; ARUP CA was 97.6% (1 ME (3%), 1 VME (2%)) and CC CA was 96.3% (1 ME (3%), 2 VMEs (4%)). Despite high error rates, the categorical agreement was acceptable (>90%) for all three antibiotics between AD and Etest. In-house susceptibility testing by gradient diffusion can allow for testing of fastidious organisms that may not survive transport to specialized laboratories; however, the method is not without technical challenges. Characterization of resistance mechanisms, increased AD dilutions, and testing from the same inoculum may determine if the observed errors reflect technical issues or breakpoints that need optimization.

IMPORTANCE Routine antimicrobial susceptibility testing (AST) of Helicobacter pylori by agar dilution is difficult to perform and not practical in most clinical microbiology laboratories. The Etest gradient diffusion method can be a reliable alternative for H. pylori AST with the advantage of being a less laborious quantitative method. This work reveals that an optimized Etest method can provide acceptable performance for H. pylori AST and describes the challenges associated with this methodology.

Comparative Effectiveness of Multiple Different First-Line Treatment Regimens for Helicobacter pylori Infection: A Network Meta-analysis

BACKGROUND & AIMS

A number of double, triple, and quadruple therapies have been proposed as first-line empiric treatments for Helicobacter pylori infection. However, knowledge of their worldwide and regional comparative efficacy is lacking. We examined the comparative effectiveness of all empirically used first-line regimens tested against standard triple treatment using a network meta-analysis of published randomized controlled trials.

METHODS

Data extracted from eligible randomized controlled trials were entered into a Bayesian network meta-analysis to investigate the comparative efficacy of H pylori infection empiric first-line regimens and to explore their effectiveness rank order. The ranking probability for each regimen was evaluated by means of surfaces under cumulative ranking values.

RESULTS

Sixty-eight eligible randomized controlled trials were included, giving a total of 92 paired comparisons with 22,975 patients randomized to 8 first-line regimens. The overall results showed that only vonoprazan triple therapy and reverse hybrid therapy achieved cure rates of >90%. Levofloxacin triple therapy performed best in Western countries (eradication rate 88.5%). The comparative effectiveness ranking showed that vonoprazan triple therapy had the best results, whereas standard triple therapy was the least efficacious regimen (surfaces under cumulative ranking 92.4% vs 4.7% respectively; odds ratio, 3.80; 95% credible interval, 1.62-8.94).

CONCLUSIONS

For first-line empiric treatment of H pylori infection, vonoprazan triple therapy and reverse hybrid therapy achieved high eradication rates of >90%. Levofloxacin triple therapy achieved the highest eradication rates in Western countries. Standard triple therapy was the least efficacious regimen in this network meta-analysis.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

The Comparison of Levofloxacin- and Clarithromycin-Based Bismuth Quadruple Therapy Regimens in Helicobacter pylori Eradication

OBJECTIVE

The aim of the current study was to compare the efficacy of quadruple therapy including levofloxacin and clarithromycin for Helicobacter pylori eradication.

METHODS

This clinical trial study was conducted on 189 patients with H. pylori infection who underwent gastroscopy and stomach biopsy in Shahid Beheshti Hospital, Kashan, Iran. After classification of patients, one group was treated with bismuth subcitrate (120 mg, 2 tablet/12 h), omeprazole (20 mg/12 h), amoxicillin (1 g/12 h), and clarithromycin (500 mg/12 h) and other group with bismuth subcitrate (120 mg, 2 tablet/12 h), omeprazole (20 mg/12h), amoxicillin (1 g/12 h), and levofloxacin (500 mg/12 h) for 2 weeks. After the end of the antibiotic treatment, omeprazole therapy was continued for 4 weeks. Two weeks after discontinuation of omeprazole, fecal antigen test was performed for both the groups to confirm the eradication of H. pylori infection.

FINDINGS

The success of H. pylori eradication in the levofloxacin and clarithromycin groups was observed in 78 (89.7%) and 71 (69.6%) patients, respectively (P < 0.01). A significant difference was also seen between the two groups in terms of side effects and its incidence (P < 0.01), so that the incidence of side effect types in the clarithromycin group was more than the levofloxacin group except muscular pain and fatigue (P < 0.01).

CONCLUSION

Levofloxacin-based quadruple regimen therapy was superior to clarithromycin-based quadruple regimens regarding H. pylori eradication and side effects. Therefore, the levofloxacin-based regimen can be considered as an effective treatment for the first-line anti-H. pylori therapy.

Reevaluation of the Efficacy of First Line Regimen for Helicobacter pylori

Background

Helicobacter pylori is a common cause of gastritis, peptic ulcer disease, and non-ulcer dyspepsia, and is also associated with gastric adenocarcinoma and mucosa associated lymphoid tissue lymphoma. Despite being known about for more than 30 years, finding an effective therapeutic strategy against it remains a challenge.

Aim

There are no US studies evaluating the efficacy of a Levofloxacin based therapy for H. pylori infection. We here intend to study the efficacy of Levofloxacin based triple antibiotic regimen as compared to Clarithromycin based triple therapy and Bismuth based quadruple therapy in our patient population.

Methods

This is a retrospective single center observational study. Patients with Helicobacter pylori infection who underwent treatment for H. pylori with one of the three therapies, i.e. Clarithromycin triple, Bismuth Quadruple or Levofloxacin triple, were included in the study and the eradication rates were compared. The confirmation of the H. pylori was done 4 weeks after the completion of anti-microbial therapy.

Results

A total of 177 individuals underwent the H. pylori treatment in our retrospective review. Of these, 54% (n=97) of patients were treated with Clarithromycin based triple therapy (Group 1), 35% (n=63) were treated with Levofloxacin based regimen (Group 2), and the remaining 11% (n=17) were treated with Bismuth based quadruple therapy (Group 3). The eradication rates were significantly higher in patients treated with Clarithromycin based triple therapy as compared to Levofloxacin based triple therapy and Bismuth quadruple therapy (78.3% vs 49.2% vs 41.1% P=0.001).

Conclusion

In conclusion, our study shows significantly lower eradication rates with Levofloxacin triple therapy among a selected US population. Thus, it may not be a good first-line therapy among this US population and the Clarithromycin based regimen may still be used successfully.

Prospective multicentre clinical study on inter- and intrapatient genetic variability for antimicrobial resistance of Helicobacter pylori

OBJECTIVES

We report on a large prospective, multicentre clinical investigation on inter- and intrapatient genetic variability for antimicrobial resistance of Helicobacter pylori.

METHODS

Therapy-naive patients (n = 2004) who had undergone routine diagnostic gastroscopy were prospectively included from all geographic regions of Austria. Gastric biopsy samples were collected separately from antrum and corpus. Samples were analysed by histopathology and real-time PCR for genotypic resistance to clarithromycin and quinolones. Clinical and demographic information was analysed in relation to resistance patterns.

RESULTS

H. pylori infection was detected in 514 (26%) of 2004 patients by histopathology and confirmed in 465 (90%) of 514 patients by real-time PCR. PCR results were discordant for antrum and corpus in 27 (5%) of 514 patients, indicating inhomogeneous infections. Clarithromycin resistance rates were 17% (77/448) and 19% (84/455), and quinolone resistance rates were 12% (37/310) and 10% (32/334) in antrum and corpus samples, respectively. Combination of test results per patient yielded resistance rates of 21% (98/465) and 13% (50/383) for clarithromycin and quinolones, respectively. Overall, infection with both sensitive and resistant H. pylori was detected in 65 (14%) of 465 patients.

CONCLUSIONS

Anatomically inhomogeneous infection with different, multiple H. pylori strains is common. Prospective clinical study design, collection of samples from multiple sites and microbiologic methods that allow the detection of coinfections are mandatory for collection of reliable data on antimicrobial resistance patterns in representative patient populations. (ClinicalTrials.gov identifier: NCT02925091).

High antibiotic resistance of Helicobacter pylori and its effect on tailored and empiric eradication of the organism in Lower Silesia, Poland

BACKGROUND

At present, the resistance to antibiotics is considered the most important reason for Helicobacter pylori (HP) eradication failure. The aim of this study was to estimate the prevalence of antimicrobial resistance of HP strains and to evaluate tailored and empiric therapeutic regimens in patients with peptic ulcer disease associated with infection of this microorganism.

MATERIALS AND METHODS

Between May 2011 and February 2013, 185 consecutive Polish patients with at least one positive Helicobacter pylori test (urease test, histopathologic examination, and/or culture) underwent eradication therapy. Those with positive culture were prescribed a tailored triple regimen, whereas those with no culture available received an empiric quadruple concomitant regimen or levofloxacin-containing triple therapy.

RESULTS

There were no HP strains resistant to amoxicillin; however, 56.7% were resistant to metronidazole, 55.2% to clarithromycin, and 5.9% to levofloxacin. Dual resistance was detected in 32.8% of individuals. Tailored and empiric therapies achieve cure rates, respectively, 95.5% and 86.6% by intention-to-treat and 95.5% and 91.3% by per-protocol analysis (P > 0.05).

CONCLUSIONS

Antibiotic resistance is notably high in Poland currently, but both tailored and empiric therapies can achieve acceptable cure rates equal to or higher than 90%.

Efficacy of 1st-line bismuth-containing quadruple therapies with levofloxacin or clarithromycin for the eradication of Helicobacter pylori infection: A 1-week, open-label, randomized trial

BACKGROUND

The aim of the present open-label, randomized control trial was to determine the clinical efficacy and safety of two 1-week bismuth-containing quadruple regimens and 1 levofloxacin-based triple regimen for the eradication of Helicobacter pylori infection in treatment-naive patients. The influence of susceptibility and host CYP2C19 polymorphisms on the efficacy was also evaluated.

METHODS

Eligible patients were randomly to receive esomeprazole and colloidal bismuth pectin along with clarithromycin and amoxicillin (EBCA), esomeprazole and colloidal bismuth pectin along with levofloxacin and amoxicillin (EBLA), or esomeprazole along levofloxacin and amoxicillin (ELA) for 1 week. The primary outcome was the eradication rate in the intention-to-treat (ITT) and per-protocol (PP) analyses.

RESULTS

Overall, 270 patients were randomized. The eradication rates in the above 3 groups were 80.25%, 89.66%, and 81.93% in PP analysis and 72.22%, 86.66%, and 75.56% in ITT analysis, respectively. The eradication rate of EBLA was significantly higher than that of EBCA (P = 0.016) in ITT analysis. No significant differences were found among these groups in terms of adverse effects and compliance. The efficacy was significantly affected by levofloxacin resistance for EBLA (P = 0.01) and ELA (P = 0.04), but not by polymorphisms of CYP2C19 gene for any of the 3 groups.

CONCLUSION

All 1-week bismuth-containing quadruple therapies and levofloxacin-based triple therapy can obtain an acceptable eradication rate, and levofloxacin-based quadruple regimen exhibits the highest eradication rate. The antibiotic resistant rate of levofloxacin was associated with the eradication rate.

Comparison of Helicobacter pylori Eradication Rates of 2-Week Levofloxacin-Containing Triple Therapy, Levofloxacin-Containing Bismuth Quadruple Therapy, and Standard Bismuth Quadruple Therapy as a First-Line Regimen

OBJECTIVE

The aim of this study was to compare the efficacy and safety of 2-week levofloxacin-containing triple therapy, levofloxacin-containing bismuth quadruple therapy, and standard bismuth-containing quadruple therapy as a first-line regimen for the eradication of Helicobacter pylori.

METHODS

A total of 329 patients with H. pylori infection were randomly divided into 3 groups to receive one of the following regimens: (a) levofloxacin-containing bismuth quadruple therapy, RBAL (rabeprazole 20 mg, b.i.d., bismuth subsalicylate 562 mg, b.i.d., amoxicillin 1 g, b.i.d, levofloxacin 500 mg, once daily), (b) standard bismuth quadruple therapy, RBMT (rabeprazole 20 mg, b.i.d, subsalicylate 562 mg, b.i.d., metronidazole 500 mg, t.i.d, tetracycline 500 mg, q.i.d), or (c) levofloxacin-containing triple therapy, RAL (rabeprazole 20 mg, b.i.d., amoxicillin 1 g, b.i.d, levofloxacin 500 mg, once daily). The primary outcome was the eradication rate in the intention-to-treat (ITT) and per protocol (PP) analysis.

RESULTS

The eradication rates of the above 3 groups using ITT analysis were RBAL 83.8%, RBMT 88.3%, and RAL 74.8% compared with 91.2, 92.5, and 79.2%, respectively, using PP analysis. The eradication rate using RBMT was significantly higher than that of RAL (p = 0.029 in ITT analysis and p = 0.017 in PP analysis). Several side effects occurred in 156 patients (54.1%) in the RBAL group, 215 (52.3%) in the RBMT group, and 56 (26.2%) in the RAL group (p > 0.05, RBAL vs. RBMT; p < 0.001, RBMT vs. RAL; p < 0.001, RBAL vs. RAL).

CONCLUSION

All bismuth-containing quadruple therapies had acceptable eradication rates, but levofloxacin-containing triple therapy was not as good as quadruple therapies. Hence, quadruple therapies should be considered the preferred first-line therapy for H. pylori infections.

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

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

The impact of amalgam dental fillings on the frequency of Helicobacter pylori infection and H. pylori eradication rates in patients treated with concomitant, quadruple, and levofloxacin-based therapies

BACKGROUND AND AIM

Mercury exposure is encountered most commonly in individuals with amalgam fillings. The toxic, bactericidal, and immunosuppressive effects of mercury are well known. Furthermore, multiple antibiotic resistance can be transferred, together with mercury resistance. The aim of this study was to investigate the frequency of Helicobacter pylori infection in dyspeptic patients with amalgam fillings and the effect of the amalgam fillings on H. pylori eradication rates in these patients.

PATIENTS AND METHODS

Four hundred and seventy-five patients who presented with dyspeptic complaints and underwent upper gastrointestinal endoscopy and gastric biopsy were included in this study. One hundred and sixty-nine (35.6%) patients were negative and 306 (64.4%) patients were positive for H. pylori. All of the participants underwent dental examinations in a blinded manner. The participants were divided into two groups on the basis of the presence of amalgam fillings. The H. pylori-positive patients were divided randomly into three subgroups: patients who received concomitant therapy (CT) (rabeprazole-amoxicillin-clarithromycin-metronidazole for 14 days; n=122); patients who received quadruple therapy (QT) (rabeprazole-tetracycline-metronidazole-colloidal bismuth subcitrate for 10 days; n=97); and patients who received levofloxacin-based therapy (LT) (rabeprazole-amoxicillin-levofloxacin for 10 days; n=87). Eradication success was detected by a urea breath test 6 weeks after the end of treatment.

RESULTS

The frequency of H. pylori infection was significantly lower in the filling group compared with the nonfilling group (53.7 and 78.8%, respectively; P<0.001). The eradication rates in the CT, QT, and LT groups were 65.5, 67.0, and 58.6%, respectively, in the intention-to-treat (ITT) analysis and 69.6, 70.7, and 62.2%, respectively, in the per-protocol (PP) analysis. In all of the H. pylori-positive patients and separately in the CT and LT groups, the eradication rates were significantly lower in the filling group compared with the nonfilling group. However, in the QT group, there was no significant difference between the patients with and without fillings (P=0.001, 0.003, 0.012, 0.14, respectively). Logistic regression analysis showed that the absence of amalgam filling exerts independent effects on the increased frequency of H. pylori infection and increased rate of H. pylori eradication.

CONCLUSION

This is the first study to show a lower frequency of H. pylori colonization in patients with amalgam fillings than without and that H. pylori eradication rates are lower in patients with amalgam fillings compared to those without.

Efficacy of levofloxacin, amoxicillin and a proton pump inhibitor in the eradication of Helicobacter pylori in Brazilian patients with peptic ulcers

OBJECTIVES

The eradication of Helicobacter (H.) pylori allows peptic ulcers in patients infected with the bacteria to be cured. Treatment with the classic triple regimen (proton pump inhibitor, amoxicillin and clarithromycin) has shown decreased efficacy due to increased bacterial resistance to clarithromycin. In our country, the eradication rate by intention to treat with this regimen is 83%. In Brazil, a commercially available regimen for bacterial eradication that uses levofloxacin and amoxicillin with lansoprazole is available; however, its efficacy is not known. Considering that such a treatment may be an alternative to the classic regimen, we aimed to verify its efficacy in H. pylori eradication.

METHODS

Patients with peptic ulcer disease infected with H. pylori who had not received prior treatment were treated with the following regimen: 30 mg lansoprazole bid, 1,000 mg amoxicillin bid and 500 mg levofloxacin, once a day for 7 days.

RESULTS

A total of 66 patients were evaluated. The patients' mean age was 52 years, and women comprised 55% of the sample. Duodenal ulcers were present in 50% of cases, and gastric ulcers were present in 30%. The eradication rate was 74% per protocol and 73% by intention to treat. Adverse effects were reported by 49 patients (74%) and were mild to moderate, with a prevalence of diarrhea complaints.

CONCLUSIONS

Triple therapy comprising lansoprazole, amoxicillin and levofloxacin for 7 days for the eradication of H. pylori in Brazilian peptic ulcer patients showed a lower efficacy than that of the classic triple regimen.

Levofloxacin for Helicobacter pylori infection: Drug resistance and safety

Helicobacter pylori (H. pylori) is an important cause of chronic gastritis and peptic ulcer, closely correlates with mucosa-associated lymphoid tissue (MALT), and is a risk factor for gastric cancer. The constantly increasing rate of resistance of H. pylori to antibiotics is the main reason for failure of H. pylori eradication therapy. How to increase the H. pylori eradication rate has become the focus of current research. Current concepts in treatment of H. pylori infection, including the Maastricht Ⅲ consensus report and Chinese consensus report in recent years, have recommended levofloxacin as a first-line or remedial therapy, and good therapeutic effects have been achieved; however, the wide use of levofloxacin has led to an increase in drug resistant strains of H. pylori. Investigation of the mechanism behind levofloxacin resistance and the security of levofloxacin has important significance to guide the clinical medication. This paper reviews the role and mechanisms of levofloxacin in H. pylori eradication, levofloxacin resistance and related molecular mechanisms, and safety of levofloxacin in the management of H. pylori infection.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Materials and Methods

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

Results

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

Conclusion

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

Eradication of Helicobacter pylori infection: Which regimen first?

Helicobacter pylori (H. pylori) is a well-known human pathogen that plays an essential role in the pathogenesis of chronic gastritis, peptic ulcer disease, and gastric malignancies. Although H. pylori is susceptible to several antimicrobials, this infection has proven challenging to cure because of the increasing prevalence of bacterial strains that are resistant to the most commonly used antimicrobials, particularly clarithromycin. An effective (i.e., > 90%) first-line therapy is mandatory for avoiding supplementary treatments and testing, and more importantly for preventing the development of secondary resistance. This study reviews the recent literature on first-line therapies for H. pylori. The eradication rates following standard triple therapy (a proton pump inhibitor plus amoxicillin and clarithromycin) for H. pylori infection are declining worldwide. Several first-line strategies have been proposed to increase the eradication rate, including extending the treatment duration to 14 d, the use of a four-drug regimen (bismuth-containing quadruple, sequential, and concomitant treatments), and the use of novel antibiotics, such as fluoroquinolones. However, the efficacy of these regimens is controversial. A first-line eradication regimen should be based on what works best in a defined geographical area and must take into account the prevalence of antimicrobial resistance in that region.

Advances in research of Helicobacter pylori resistance to levofloxacin

Helicobacter pylori (H. pylori) has been identified as the most important risk factor for chronic active gastritis and peptic ulcer disease. Resistance to antibiotics is increasing in H. pylori and is the main reason for failure of H. pylori eradication therapy. It is now widely accepted that resistance to fluoroquinolones (levofloxacin) is related with mutations of H. pylori gyrA gene. Molecular mechanisms of and detection methods for H. pylori resistance to levofloxacin have become the focus of current research. Therefore, study on H. pylori resistance to antibiotics is of great significance for eradication therapy of H. pylori infection.

[Ideal treatment for Helicobacter pylori: a systematic review]

BACKGROUND

The success rates of therapies for treating Helicobacter pylori vary greatly worldwide and the ideal treatment has yet to be clearly established.

AIMS

A systematic review was carried out to evaluate the effectiveness of current first and second-line therapies in treating H.pylori infection.

METHODS

Two researchers independently carried out Internet search engine reviews (PUBMED, EMBASE, MEDLINE) of clinical trials on adults published between 1990 and 2012 in both English and Spanish.

RESULTS

Forty-three (n=8,123) clinical trials were evaluated that included first and second-line triple, quadruple, and sequential therapies. The eradication rates of the standard triple therapy are unacceptable (≤80%) in countries where H.pylori is highly resistant to clarithromycin and metronidazole. Administration of the standard triple therapy for more than 7 days does not improve its effectiveness. No statistically significant differences were observed between the eradication rates of the quadruple therapy with bismuth and the standard triple therapy. Even though the sequential and concomitant therapies are equally successful regimens, the triple therapy with levofloxacin offers the best results as first and second-line treatment, but quinolone resistance can diminish its effectiveness. The triple therapy with levofloxacin and the sequential and concomitant treatments were superior to the standard triple regimen as first-line therapy.

CONCLUSIONS

Currently there is no ideal first or second-line treatment for achieving 100% eradication. The therapeutic order should be carried out according to the initial treatment and local antimicrobial resistance studies.

Sequential versus triple therapy for the first-line treatment of Helicobacter pylori: a multicentre, open-label, randomised trial

BACKGROUND

Whether sequential treatment can replace triple therapy as the standard treatment for Helicobacter pylori infection is unknown. We compared the efficacy of sequential treatment for 10 days and 14 days with triple therapy for 14 days in first-line treatment.

METHODS

For this multicentre, open-label, randomised trial, we recruited patients (≥20 years of age) with H pylori infection from six centres in Taiwan. Using a computer-generated randomisation sequence, we randomly allocated patients (1:1:1; block sizes of six) to either sequential treatment (lansoprazole 30 mg and amoxicillin 1 g for the first 7 days, followed by lansoprazole 30 mg, clarithromycin 500 mg, and metronidazole 500 mg for another 7 days; with all drugs given twice daily) for either 10 days (S-10) or 14 days (S-14), of 14 days of triple therapy (T-14; lansoprazole 30 mg, amoxicillin 1 g, and clarithromycin 500 mg for 14 days; with all drugs given twice daily). Investigators were masked to treatment allocation. Our primary outcome was the eradication rate in first-line treatment by intention-to-treat (ITT) and per-protocol (PP) analyses. This trial is registered with ClinicalTrials.gov, number NCT01042184.

FINDINGS

Between Dec 28, 2009, and Sept 24, 2011, we enrolled 900 patients: 300 to each group. The eradication rate was 90·7% (95% CI 87·4-94·0; 272 of 300 patients) in the S-14 group, 87·0% (83·2-90·8; 261 of 300 patients) in the S-10 group, and 82·3% (78·0-86·6; 247 of 300 patients) in the T-14 group. Treatment efficacy was better in the S-14 group than it was in the T-14 group in both the ITT analysis (number needed to treat of 12·0 [95% CI 7·2-34·5]; p=0·003) and PP analyses (13·7 [8·3-40], p=0·003). We recorded no significant difference in the occurrence of adverse effects or in compliance between the three groups.

INTERPRETATION

Our findings lend support to the use of sequential treatment as the standard first-line treatment for H pylori infection.

FUNDING

National Taiwan University Hospital and National Science Council.

Safety and efficacy of 1-week levofloxacin-based triple therapy in first-line treatment for Helicobacter pylori-related peptic ulcer disease in Kashmir, India

BACKGROUND AND OBJECTIVES

There is no ideal therapy for eradication of Helicobacter pylori infection. We evaluated the efficacy and safety of 1-week triple therapy with rabeprazole, levofloxacin, and tinidazole in a metronidazole resistance prevalent region for eradicating H. pylori infection in patients with gastroduodenal ulcers.

METHODS

This was an open-label, prospective study. Consecutive patients with endoscopy-proven duodenal or gastric ulcer and who were H. pylori-positive were treated with levofloxacin 500 mg once a day, rabeprazole 20 mg twice a day, and tinidazole 500 mg twice daily for 7 days followed by rabeprazole 20 mg OD for 8 weeks. Endoscopy was repeated 8 weeks after the end of therapy to check for ulcer healing and H. pylori status.

RESULTS

One hundred and thirty-one patients with gastroduodenal ulcers (duodenal 118, and gastric 13) were included. Drug compliance was 97.7 %. The eradication rate of H. pylori by intention-to-treat analysis was 85.5 % (95 % confidence interval 79.5-91.5) (112 of 131 patients) and by per-protocol analysis was 91.8 % (95 % confidence interval 86.9-96.7) (112 of 122 patients). Adverse effects were reported in 17 %: abdominal pain in 3.05 %, metallic taste in 6.87 %, and nausea and vomiting in 4.58 %.

CONCLUSIONS

Levofloxacin-tinidazole-based triple therapy was highly effective and safe as a first-line regimen in Indian patients with gastroduodenal ulcer disease associated with H. pylori infection. The regimen was well tolerated.

Levofloxacin-containing triple and sequential therapy or standard sequential therapy as the first line treatment for Helicobacter pylori eradication in China

AIMS

To compare the efficacy and the adverse effects of levofloxacin-containing triple therapy, standard sequential therapy, and levofloxacin-containing sequential therapy as first-line treatment for Helicobacter pylori eradication.

METHODS

Three hundred and forty-five naive H. pylori-positive patients were randomized to receive levofloxacin-containing 7-day triple therapy (Levo triple, i.e., esomeprazole, 20 mg, twice daily, amoxicillin, 1 g, twice daily, and levofloxacin, 500 mg, once daily for 7 days, n = 114), standard sequential therapy (SST-10, 5-day esomeprazole, 20 mg, twice daily and amoxicillin, 1 g, twice daily followed by 5-day esomeprazole, 20 mg, twice daily, clarithromycin, 500 mg, twice daily and tinidazole, 500 mg, twice daily for 5 days, n = 115) or levofloxacin-containing sequential therapy (Levo-ST-10, 5-day esomeprazole, 20 mg, twice daily and amoxicillin, 1 g, twice daily for 5 days followed by 5-day esomeprazole, 20 mg, twice daily, levofloxacin, 500 mg, once daily and tinidazole, 500 mg, twice daily, n = 116). Eradication was confirmed by a (13) C-urea breath test 4 weeks after completion of treatment.

RESULTS

Intention to treat (ITT) eradication rates were 78.1% (95% CI: 69.4, 85.3%), 78.3% (95% CI: 69.6, 85.4%), and 82.8% (95% CI: 74.6, 89.1%) for Levo triple, SST-10, Levo-ST-10, respectively (p = .599). Per protocol (PP) eradication rates were 80.9% (95% CI: 72.3, 87.8%), 82.6% (95% CI: 74.1, 89.2%), and 86.5% (95% CI: 78.7, 92.2%), respectively, for the three therapies (p = .513). Overall, 3.8% experienced mild to moderate adverse events; the rates were 1.75, 4.35, and 5.17%, respectively, in the three groups (p = .325).

CONCLUSIONS

Standard sequential therapy and 7-day levofloxacin triple therapy produced unacceptably therapeutic efficacy in China. Only levofloxacin-containing sequential therapy achieved borderline acceptable result. None of the regimens tested reliably achieved 90% or greater therapeutic efficacy in China.

Primary and secondary clarithromycin, metronidazole, amoxicillin and levofloxacin resistance to Helicobacter pylori in southern Poland

The aim of this study was to assess the primary and secondary resistance of H. pylori strains cultured from adult patients of the Małopolska region of Poland, mainly of Kraków and the surrounding areas, to antibacterial agents (amoxicillin, clarithromycin, metronidazole and levofloxacin). In total, 115 H. pylori strains were isolated, of which 90 strains originated from patients who had never been treated for H. pylori infection, while the remaining 25 were isolated from patients in whom eradication of the infection failed after treatment. All tested H. pylori strains were susceptible to amoxicillin. Forty-four percent of strains isolated were resistant to metronidazole. The primary and secondary resistance to this antimicrobial chemotherapeutic reached 37% and 72% (p = 0.002), respectively. In total, 34% of strains were resistant to clarithromycin, and the ratio of strains with secondary resistance was significantly greater than that of the strains with primary resistance (80% vs. 21%, p < 0.001). The double resistance to both metronidazole and clarithromycin was confirmed in 23% of H. pylori strains. Five percent of H. pylori strains were resistant to levofloxacin, while primary and secondary resistance to this drug accounted for 2% and 16% (p = 0.006), respectively. In total, 4% of H. pylori strains were simultaneously resistant to metronidazole, clarithromycin and levofloxacin. Thus, the high resistance to metronidazole and clarithromycin excludes the possibility of using these drugs for treatment of H. pylori infection without earlier antibiogramming. Levofloxacin, as a drug of high efficacy against H. pylori, should be reserved for an "emergency" therapy and used in a limited capacity in order to preserve its potent antimicrobial activity. The Polish Society of Gastroenterology recommends levofloxacin as a third-line therapy.

Empirical modified sequential therapy containing levofloxacin and high-dose esomeprazole in second-line therapy for Helicobacter pylori infection: a multicentre clinical trial

OBJECTIVES

Sequential therapy appears to achieve a higher Helicobacter pylori eradication rate than triple therapy. We assessed the efficacy and tolerability of modified sequential therapy containing levofloxacin and high-dose esomeprazole in second-line therapy.

METHODS

Patients who failed first-line triple therapy with clarithromycin, amoxicillin and a proton pump inhibitor were eligible in this multicentre trial. Eligible patients were treated with esomeprazole 40 mg and amoxicillin 1 g for the first 5 days, followed by esomeprazole 40 mg, levofloxacin 250 mg and metronidazole 500 mg for another 5 days (all given twice daily). Eradication was confirmed with a (13)C-urea breath test 6 weeks after therapy. Drug susceptibility, presence/absence of gyrA mutation and CYP2C19 genotype were also determined.

RESULTS

A total of 142 patients were enrolled. The eradication rate was 95.1% [135/142, 95% confidence interval (CI) 91.5%-98.6%] in the intention-to-treat analysis and 96.4% (133/138, 95% CI 93.3%-99.5%) in the per protocol analysis. Four patients (2.8%) failed to take at least 80% of the drugs due to adverse effects. The eradication rates were 50% (4/8) and 97.7% (43/44) in patients with and without metronidazole resistance, respectively (P = 0.001). The eradication rates were 84.6% (11/13) and 95.1% (58/61) in patients with and without gyrA mutation, respectively (P = 0.210). The eradication rates were not affected by the CYP2C19 polymorphism (P = 0.421).

CONCLUSIONS

This modified sequential therapy achieved an excellent eradication rate (>95%) in second-line treatment and the eradication rate appeared to be affected by metronidazole resistance.

Preparation of a novel floating ring capsule-type dosage form for stomach specific delivery

Study objectives were to develop a unique floating ring capsule dosage form which combines gastric soluble and insoluble portions, and to evaluate its suitability for stomach specific drug delivery. New floating ring capsules were developed using different polymers and were compared for various parameters. The formulation with HPMC and sodium CMC has better floating properties. The effects of polymers concentration on drug release were studies by in vitro release studies. The interaction studies of combined drug with polymers were determined using FT-IR spectroscopy. The entrapped air within the gel barrier and lower densities of HPMC and sodium CMC resulted in better floating behavior. Steady slow gel formations showed prolonged drug release. The in vitro release rates were generally found to be faster with low concentration of carbopol showing release within 2 h, while formulations containing high amount of HPMC showed release in 8 h. In particular, the higher concentration of HPMC formulation shows the best drug release performance. A very low change in peak shift was observed only with sodium alginate formulations. Further, FT-IR measurements confirmed the absence of any chemical interactions. Results indicate that new floating ring capsule is a promise dosage form for stomach specific delivery.

Should quinolones come first in Helicobacter pylori therapy?

New generations of fluoroquinolones, like levofloxacin and moxifloxacin, exhibit a broad-spectrum activity against Gram-positive and Gram-negative bacteria, and have been successfully introduced into the treatment of Helicobacter pylori infection. Based on a large body of evidence, current guidelines recommend the use of levofloxacin- or moxifloxacin-containing proton-pump inhibitor (PPI) triple therapies in second-line or rescue treatment of H. pylori infection. The efficacy of standard PPI triple therapies has substantially declined during the last decade, mainly due to increasing resistance against the key antibiotics clarithromycin and metronidazole. Therefore, alternative strategies for first-line therapy of H. pylori infection have been evaluated in a considerable number of clinical trials including sequential regimens, nonbismuth quadruple regimens, and quinolone-containing PPI triple therapy regimens. The aim of this paper is to summarize the current body of evidence of levofloxacin- and moxifloxacin-containing regimens in first-line treatment of H. pylori infection, and to discuss the risks and benefits of these strategies in the light of increasing resistance of H. pylori to quinolones.

Comparison of two different treatment protocols in Helicobacter pylori eradication

BACKGROUND

The prevalence of Helicobacter pylori (H pylori) in Turkey is high and eradication rates are low. As a result, alternative treatment strategies are required.

OBJECTIVES

To evaluate the status of H pylori eradication in Turkey by comparing the results of this study to other studies reported in the literature.

METHODS

Two hundred and eighty-two patients diagnosed with H pylori were included in this study. Patients were randomized into two groups. The first group consisted of 138 patients receiving 30 mg lansoprazole bid, amoxicillin 1 g bid, and clarithromycin 500 mg bid for 14 days. The second group consisted of 144 patients who received lansoprazole 30 mg bid and amoxicillin 1 g bid for seven days, followed by metronidazole 500 mg bid, tetracycline 500 mg qid, and lansoprazole 30 mg bid for an additional seven days.

RESULTS

H pylori eradication rates in the first group were 53.6% according to intention-to-treat analysis, and 52.5% according to per protocol analysis. In the second group, eradication rates were 72.2% per intention-to-treat analysis and 77.6% as per protocol analysis. H pylori eradication rates in the second group were significantly higher than the first group (P=0.001, P<0.05), whereas the incidence of adverse events in the second group was significantly lower (P=0.048, P<0.05).

CONCLUSION

This study found a significant difference in eradication rates between the traditional triple therapy and modified sequential therapy groups. As a result, modified sequential therapy shows promise as an alternative treatment.

Genotypic resistance in Helicobacter pylori strains correlates with susceptibility test and treatment outcomes after levofloxacin- and clarithromycin-based therapies

The accuracy of genotypic resistance to levofloxacin (gyrA mutations) and its agreement with treatment outcomes after levofloxacin-based therapy have not been reported. We aimed to assess the correlation. Helicobacter pylori strains isolated from patients who received levofloxacin-based and clarithromycin-based triple therapies in a previous randomized trial were analyzed for point mutations in gyrA and 23S rRNA. PCR followed by direct sequencing was used to assess the gyrA and 23S rRNA mutations. An agar dilution test was used to determine the MICs of clarithromycin and levofloxacin. We found that the agreement between genotypic and phenotypic resistance to levofloxacin was best when the MIC breakpoint was >1 μg/ml (kappa coefficient, 0.754). The eradication rates in patients with and without gyrA mutations were 41.7% and 82.7%, respectively (P = 0.003). The agreement between genotypic and phenotypic resistance to clarithromycin was best when the MIC breakpoint was >2 μg/ml (kappa, 0.694). The eradication rates in patients with and without 23S rRNA mutations were 7.7% and 93.5%, respectively (P < 0.001). The agreements (kappa coefficient) between therapeutic outcomes after clarithromycin-based triple therapy and genotypic and phenotypic resistance were 0.671 and 0.356, respectively. The agreements (kappa coefficient) between therapeutic outcomes after levofloxacin-based triple therapy and genotypic and phenotypic resistance were 0.244 and 0.190, respectively. In conclusion, gyrA and 23S rRNA mutations in H. pylori strains appeared to be better markers than phenotypic resistance in the prediction of treatment outcomes. The optimal breakpoints for levofloxacin and clarithromycin resistance appeared to be >1 μg/ml and >2 μg/ml, respectively.

Comparison of the once-daily levofloxacin-containing triple therapy with the twice-daily standard triple therapy for first-line Helicobacter pylori eradication: a prospective randomised study

BACKGROUND/AIMS

Simple compound of Helicobacter pylori eradication therapy may improve drug compliance of patients. The aims of this study were to compare the efficacy and tolerability of a simple combination containing levofloxacin 7-day once-daily with standard twice-daily triple therapy.

PATIENTS AND METHODS

This was a prospective, randomised, open-label trial. A total of 189 consecutive patients diagnosed with peptic ulcer and H. pylori infection were enrolled. Patients were randomly divided into two groups: LEC group--levofloxacin 500 mg, esomeprazole 40 mg and clarithromycin 500 mg once daily for 7 days; AEC group--amoxicillin 1 g, esomeprazole 40 mg and clarithromycin 500 mg twice daily for 7 days.

RESULTS

There were 90 patients in the LEC group and 99 patients in the AEC group. By intention-to-treat and per-protocol analysis, the H. pylori eradication rate was 78.9% [71/90; 95% confidence interval (CI), 70.3-87.5%] and 83.5% (71/85; 95% CI, 75.5-91.6%) respectively, in the LEC group; and 74.8% (74/99; 95% CI, 66.0-83.5%) and 86.0% (74/86; 95% CI, 78.6-93.5%) respectively, in the AEC group. The incidence and tolerability of side effects were similar between these two groups.

CONCLUSION

The efficacy and tolerability of once-daily levofloxacin-containing triple therapy are equal to those of the standard twice-daily triple therapy in this study. However, none of the treatment regimens evaluated achieved enough eradication efficacies to be considered as a recommendable first-line treatment.

Efficacy and safety of Levofloxacin, Clarithromycin and Esomeprazol as first line triple therapy for Helicobacter pylori eradication in Middle East. Prospective, randomized, blind, comparative, multicenter study

BACKGROUND/AIMS

Antibiotic resistance and poor compliance are the main causes of Helicobacter pylori (H. pylori ) eradication failure. This study evaluated the eradication rate, tolerability, and compliance of Levofloxacin, Clarithromycin and Esomeprazol combined triple therapy for H. pylori eradication.

PATIENTS AND METHODS

Four hundred-fifty patients from 3 centres who were diagnosed to have Helicobacter pylori infection by (13)C-urea breath test were randomized into 3 equal groups; group 1 (CAE) received Clarithromycin 500mg twice daily, Amoxicillin 1000mg twice daily, plus Esomeprazol 20mg twice daily for 7 days, group 2 (LAE) received Levofloxacin 500mg once daily, Amoxicillin 1000mg twice daily, plus Esomeprazol 20mg twice daily for 7 days, group 3 (CLE) received Levofloxacin 500mg once daily, Clarithromycin 500mg twice daily, plus Esomeprazol 20mg twice daily for 7 days. 436 patients were re-evaluated by (13)C-urea breath test after 6weeks from completion of treatment.

RESULTS

H. pylori eradication (intention to treat) was successful in 136/150 (90.6%) with CLE, 127/150 (84.7%) with LAE and 118/150 (78.6%) with CAE. There was a significant difference (p<0.001) regarding treatment success between CLE and LAE when compared with CAE. There was no difference among the treatment groups with regard to the incidence and severity of adverse events reported.

CONCLUSION

The combined Levofloxacin, and Clarithromycin and Esomeprazol based regimen as first line triple therapy for H. pylori eradication can give more significant eradication rate with same safety when compared with classic triple therapy.

In vitro activity of nemonoxacin, tigecycline, and other antimicrobial agents against Helicobacter pylori isolates in Taiwan, 1998-2007

The minimum inhibitory concentrations (MICs) of 330 nonduplicate Helicobacter pylori isolates to nemonoxacin, tigecycline, and eight other antimicrobial agents were determined by using the agar dilution method. Sequencing the quinolone resistance-determining regions (QRDRs) in the gyrA gene of these isolates was also performed. Resistance to clarithromycin showed an increasing trend during the ten-year study period and was highest (38%) in 2005. Tigecycline had potent in vitro activities against all isolates, with an MIC(90) of 0.06 μg/ml. Among the quinolones tested, nemonoxacin (MIC(50) of 0.12 μg/ml and MIC(90) of 0.25 μg/ml) and gemifloxacin had one to two-fold better in vitro activities than ciprofloxacin, levofloxacin, and moxifloxacin. Among the nine isolates (2.7%) with levofloxacin resistance, four (44.4%) were also resistant to metronidazole, three (33.3%) to clarithromycin, and two (22.2%) to amoxicillin. Isolates with levofloxacin resistance exhibited one or two of three amino acid alterations (Ser-70, Asn-87, and Asp-91) involved in QRDRs in the gyrA gene. A double mutation at Ser70Cys and Asn87Ile had a higher level of resistance. The results of this study suggest a potentially useful role of nemonoxacin and tigecycline in the treatment of infections caused by H. pylori. The gyrA mutation at Ser-70 is a novel finding and has an impact on levofloxacin resistance.

Advantages of Moxifloxacin and Levofloxacin-based triple therapy for second-line treatments of persistent Helicobacter pylori infection: a meta analysis

OBJECTIVE

The main aim of this meta-analysis was to compare the efficacy and safety of clarithromycin and second-generation fluoroquinolone-based triple therapy vs. bismuth-based quadruple therapy for the treatment of persistent Helicobacter pylori infection.

METHODS

A systematic literature search was conducted for articles and abstracts from 1981 to March 2009 using Medline, PubMed, EMBase, Google Scholar and CNKI (Chinese), Wanfang (Chinese) digital database and recent Digestive Disease Week, United European Gastroenterology Week, and European Helicobacter Study Group conferences were also performed. Boolean operators (NOT, AND, OR) were used in succession to narrow and widen the search. Sixteen articles and four abstracts met the inclusion criteria, and were included in the meta-analysis by using Review Manager 4.2.8.

RESULTS

The eradication rates demonstrated that clarithromycin-based triple therapy is inferior to bismuth-based quadruple therapy (OR = 0.53, 95% CI: 0.35-0.80, P = 0.002). Thirteen RCTs compared levofloxacin-based triple therapy vs. bismuth-based quadruple therapy, the eradication rates of the two regimens were shown to have no significant difference (OR = 1.43, 95% CI: 0.82-2.51, P = 0.21). But the eradication rates demonstrated superiority of the 10-day levofloxacin-based triple therapy over 7-day bismuth-based quadruple therapy (OR = 4.79, 95% CI: 2.95-7.79, P < 0.00001). Levofloxacin-based triple therapy was better tolerated than bismuth-based quadruple therapy with lower rates of side effects (OR = 0.41, 95% CI: 0.27-0.61, P < 0.0001), and lower rates of discontinuation of therapy due to adverse events (OR = 0.13, 95% CI: 0.06-0.33, P < 0.0001). Furthermore, our meta-analysis suggested that the eradication rates of the moxifloxacin-based triple therapy has a slight superiority to bismuth-based quadruple therapy, but there was no significant difference between them.

CONCLUSION

Second-generation fluoroquinolone-based triple therapy can be suggested as the regimen of choice for rescue therapy in the eradication of persistent H. pylori infection especially 10-day levofloxacin-based triple therapy.

High efficacy of 14-day triple therapy-based, bismuth-containing quadruple therapy for initial Helicobacter pylori eradication

BACKGROUND

The success rate of currently recommended 7-day triple therapy with a PPI plus amoxicillin and clarithromycin has fallen into the unacceptable range. It is urgent to look for a new strategy to treat the infection of Helicobacter pylori.

AIMS

To observe the efficacy of triple therapy-based, bismuth-containing quadruple therapy for H. pylori treatment.

METHODS

A total of 160 patients with functional dyspepsia who were Hp+ were randomly assigned into two groups. Regimen: Omeprazole 20 mg, Amoxicillin 1.0 g, Clarithromycin 500 mg and Bismuth Potassium Citrate 220 mg, twice a day. Eighty patients received 7-day quadruple therapy and 80 patients received the same therapy for 14 days. Six weeks after treatment, H. pylori eradication was assessed by (13)C-urea breath test. Minimal inhibitory concentrations of metronidazole, clarithromycin and amoxicillin of clinical isolates were determined by the twofold agar dilution method.

RESULTS

Fourteen-day therapy led to a significant increase of H. pylori eradication success when compared to 7-day therapy in the intention-to-treat analysis (93.7 vs 80.0%; p = .01), and the per-protocol analysis (97.4 vs 82.0%; p = .0016). The H. pylori resistance rates to metronidazole, clarithromycin and amoxicillin were 42.1, 18.0 and 0%. Fourteen-day therapy was significantly more effective in patients with clarithromycin-resistant strains. Incidences of adverse events were comparable.

CONCLUSIONS

Addition bismuth and prolonging treatment duration can overcome H. pylori resistance to clarithromycin and decrease the bacterial load. Fourteen-day triple therapy-based, bismuth-containing quadruple therapy achieved ITT success rate 93% and could be recommended as the first line eradication regimen.

The modified sequential treatment regimen containing levofloxacin for Helicobacter pylori eradication in Turkey

BACKGROUND

Eradication rates of Helicobacter pylori have declined to unacceptable levels in recent years. New and effective treatment options are warranted both as a first and second line treatment.

AIM

To test an effectiveness of modified sequential therapy with levofloxacin for H. pylori eradication in Turkey.

MATERIAL AND METHODS

Helicobacter pylori infected dyspeptic patients were included to the study. Subjects were treated with modified sequential therapy consisting of rabeprazole 20 mg b.i.d. and amoxicillin 1 g b.i.d., for 7 days followed by rabeprazole 20 mg b.i.d, levofloxacin 500 mg q.d. and metronidazole 500 mg b.i.d for the remaining 7 days.

RESULTS

Sixty-three treatment naive patients and 37 previous treatment failures were enrolled to the study (59 F, 41 M, age: 21-80 years). There was five drop out. Helicobacter pylori eradication was achieved in 80 patients, intention-to-treat (ITT): 80% (95% CI: 71-87%) and per-protocol (PP): 84.2% (95% CI: 75-91%), totally. In treatment naive patients ITT and PP eradication rates were 82.5% (95% CI: 71-91%), and 86.7% (95% CI: 75-94%), respectively. As a second line treatment eradication was successful in ITT 75.7%.(95% CI: 59-88%), and PP 80% (95% CI: 63-92%).Mild side effects were reported by 8 patients (8.4%).

CONCLUSIONS

Sequential therapy using "rabeprazole and amoxicillin 7 days followed by rabeprazole, metronidazole and levofloxacin for 7 days" is a new regimen with acceptable eradication rates in naïve patients in Turkey. Further modifications in the dose or duration of this new sequential therapy might increase its effectiveness as both first and second line treatment.

Clarithromycin-amoxycillin-containing triple therapy: a valid empirical first-line treatment for Helicobacter pylori eradication in Hong Kong?

BACKGROUND

Recent studies have suggested the eradication rate for Helicobacter pylori infection with standard amoxycillin-clarithromycin-containing triple therapy as first-line treatment have fallen below 80%. Levofloxacin-containing triple therapy was proposed as an alternative. The aim of this study is to compare the efficacy and tolerability of the standard 7-day clarithromycin-containing triple therapy against the 7-day levofloxacin-containing triple therapy, and to assess whether the classical triple therapy is still valid as empirical first-line treatment for H. pylori infection in Hong Kong.

METHODS

Three hundred consecutive H. pylori-positive patients were randomized to receive either 1 week of EAL (esomeprazole 20 mg b.d., amoxycillin 1 g b.d., and levofloxacin 500 mg daily) or EAC (esomeprazole 20 mg b.d., amoxycillin 1 g b.d., and clarithromycin 500 mg b.d.). H. pylori status was rechecked by (13)C-urea breath test 6 weeks after treatment. Patients who failed either of the first-line eradication therapy were invited to undergo H. pylori susceptibility testing.

RESULTS

H. pylori eradication was achieved in 128 of 150 (85.3%) patients in EAL and 139 of 150 (92.7%) patients in EAC groups, respectively (p = .043), for both intention-to-treat and per-protocol analysis. More patients in the clarithromycin- than the levofloxacin-containing therapy group developed side effects from the medication (21.3% vs 13.3%, p = .060). Nine patients (six from the EAL group and three from the EAC group) who failed their corresponding eradication therapy returned for susceptibility testing. All nine isolates were highly resistant to levofloxacin (minimum inhibitory concentration or MIC > 32 microg/mL), whereas only two of the six isolates from the EAL group were resistant to clarithromycin (MIC > 0.5 microg/mL).

CONCLUSIONS

The standard 7-day clarithromycin-containing triple therapy is still valid as the most effective empirical first-line eradication therapy for H. pylori infection in Hong Kong, as prevalence of primary resistance of H. pylori to amoxycillin and clarithromycin remains low. Patients who failed their empirical first-line eradication therapy should undergo H. pylori susceptibility testing to guide further treatment.

Resistance to metronidazole, clarithromycin and levofloxacin of Helicobacter pylori before and after clarithromycin-based therapy in Taiwan

BACKGROUND AND AIM

Clarithromycin-based triple therapy has been commonly applied as the first-line therapy for Helicobacter pylori eradication. Levofloxacin could serve as an alternative in either first-line or second-line regimens. This study surveyed the prevalence of levofloxacin resistance of H. pylori isolates in naive patients and in patients with a failed clarithromycin-based triple therapy.

METHODS

The study collected the H. pylori isolates from 180 naive patients and 47 patients with a failed clarithromycin-based triple therapy. Their in vitro antimicrobial resistance was determined by E-test.

RESULTS

The naive H. pylori isolates had resistance rates for amoxicillin, levofloxacin, clarithromycin and metronidazole of 0%, 9.4%, 10.6% and 26.7%, respectively. An evolutional increase of the primary levofloxacin resistance was observed in isolates collected after 2004, as compared to isolates collected before 2004 (16.3% vs 3.2%, P = 0.003). There was no evolutional increment of the primary clarithromycin resistance. The clarithromycin resistance elevated significantly after a failed clarithromycin-based triple therapy (78.7% vs 10.6%, P < 0.001). The post-treatment isolates remained to have a levofloxacin resistance rate of near 17%, but the levofloxacin-resistant isolates were correlated with a higher incidence of metronidazole resistance (P = 0.023). No strain was found to be resistant to amoxicillin even after eradication failure.

CONCLUSION

The levofloxacin resistance of naive H. pylori remains less than 10% in Taiwan. With relatively lower resistance to levofloxacin than to metronidazole of the H. pylori isolates collected after a failed clarithromycin-based therapy, proton pump inhibitor-levofloxacin-amoxicillin may be an alternative choice to serve as the second-line therapy.

Second-line levofloxacin-based triple schemes for Helicobacter pylori eradication

BACKGROUND

The recommended second-line therapy for Helicobacter pylori (H. pylori) eradication is a quadruple regimen that fails in up to 30% of patients. Several recent studies suggest levofloxacin-based triple therapies as an alternative rescue treatment. However, dosage and length of levofloxacin-based regimens have not been established.

AIM

To compare the efficacy and tolerability of four second-line levofloxacin-based schemes for H. pylori eradication.

METHODS

One hundred and sixty patients (aged 18-70 years, 72 male patients) who were H. pylori positive after standard triple therapies were randomised to receive esomeprazole 20mg b.d. and amoxicillin 1g b.d. plus levofloxacin 500 mg o.d., for 7 or 10 days (Groups A and B) or levofloxacin 500 mg b.d. for 7 days or 10 days (Groups C and D). H. pylori status was assessed by 13-C Urea Breath Test or rapid urease test, before and 6 weeks after therapy. Incidence of side effects was evaluated by a questionnaire.

RESULTS

No dropouts were observed. Eradication of H. pylori infection was successful in: 65% of patients in Group A; 90% in Group B; 70% in Group C; 85% in Group D. Based upon duration of treatment, eradication rates were: 67.5% in 7 days groups and 87.5% in 10 days groups (p=0.004). Dosage of levofloxacin did not affect the eradication rates (77.5% both in the once daily and twice daily groups). Mild adverse events were reported overall in 16% of patients (22.5% in 7 days groups; 27.5% in 10 days groups; p=0.58; 12% in the once daily group; 32.5% in the twice daily group; p=0.04).

CONCLUSIONS

10 days levofloxacin-based second-line regimens were effective in curing H. pylori infection in more than 85% of patients with a lower incidence of adverse effects in levofloxacin single-dosage scheme. The 10 days levofloxacin-based regimens were more effective than 7 days course of treatment showing that duration of therapy is the crucial factor affecting eradication rate.

Sitafloxacin activity against Helicobacter pylori isolates, including those with gyrA mutations

Sitafloxacin showed MICs of less than or equal to 0.5 microg/ml against 105 isolates of Helicobacter pylori, including 44 isolates with mutations in the gyrA gene. The highest MICs for garenoxacin and levofloxacin were 8 and 64 times, respectively, higher than the highest MICs observed for sitafloxacin.

Prevalence of primary fluoroquinolone resistance among clinical isolates of Helicobacter pylori at a University Hospital in Southern Taiwan

BACKGROUND

Fluoroquinolone-containing therapy is effective in eradicating Helicobacter pylori. However, the resistance rate of H. pylori to fluoroquinolones in Taiwan has not yet been reported. In this study, we aimed to investigate the susceptibility to antibiotics commonly used in eradication schedules and fluoroquinolones in H. pylori.

METHODS

A total of 210 clinical isolates of H. pylori were collected from April 1998 to September 2007 from patients in southern Taiwan. The in vitro activities of six antimicrobial agents were determined by the agar dilution method and Etest. The mutations in quinolone resistance-determining regions of gyrA and gyrB were investigated by direct sequencing.

RESULTS

Overall, 5.7% of the isolates were resistant to ciprofloxacin and levofloxacin. The resistance rate to amoxicillin, clarithromycin, metronidazole, and tetracycline was 1.0% (two of 210), 9.5% (20 of 210), 27.6% (58 of 210), and 0.5% (one of 210), respectively. The resistance rate to either ciprofloxacin or to levofloxacin increased from 2.8% (1998-2003) to 11.8% (2004-2007). The mutations in gyrA at N87 or D91 had an impact on primary fluoroquinolone resistance in H. pylori. Garenoxacin, but not moxifloxacin, had a good in vitro inhibitory effect against ciprofloxacin/levofloxacin-resistant strains compared with objective minimal inhibitory concentration values.

CONCLUSIONS

Drug resistance to ciprofloxacin and levofloxacin in H. pylori collected from 2004 to 2007 increased significantly compared with resistance level observed during 1998-2003. The continuous surveillance of quinolone resistance among H. pylori is important in this area.

Second-line treatment for Helicobacter pylori infection: 10-day moxifloxacin-based triple therapy versus 2-week quadruple therapy

BACKGROUND AND AIM

The aim of this study was to test the efficacy of 10-day moxifloxacin-based triple therapy versus 2-week quadruple therapy for the second-line treatment of Helicobacter pylori infection.

METHODS

One hundred and ninety-two patients who had failed previous H. pylori eradication on standard triple therapy were randomized to one of two regimens: 1, moxifloxacin (400 mg q.d.), amoxicillin (1000 mg b.i.d.), and esomeprazole (20 mg b.i.d.) for 10 days (the 10MEA group), or 2, esomeprazole (20 mg b.i.d.), tripotassium dicitrate bismuthate (300 mg q.i.d.), metronidazole (500 mg t.i.d.), and tetracycline 500 mg (q.i.d.) for 14 days (the 14EBMT group). The eradication rates, drug compliances, and side-effect rates of these two regimens were compared.

RESULTS

Eradication rates by intention-to-treat and per-protocol analyses in the 10MEA and 14EMBT groups were 71.9% and 82.6%, and 71.7% and 90.5% (p = .973 and .321), respectively. The 10MEA group was significantly superior to the 14EMBT group in terms of side-effect rates (12.2% vs. 39.6%, p = .001), and discontinuation rates due to side-effects were lower in the 10MEA group than in the 14EMBT group (0.7% vs. 13.2%, p < .001). Moreover, compliance was higher in the 10MEA group (94.2% (131/139)) than in the 14EBMT group (83.0% (44/53)) (p = .014).

CONCLUSION

The 10-day moxifloxacin-based triple therapy was found to have a high eradication rate with few side-effects and good drug compliance. These findings suggest that this regimen is a safe and effective second-line treatment option for H. pylori infection in Korea.

Rational prescription of drugs within similar therapeutic or structural class for gastrointestinal disease treatment: Drug metabolism and its related interactions

AIM: To review and summarize drug metabolism and its related interactions in prescribing drugs within the similar therapeutic or structural class for gastrointestinal disease treatment so as to promote rational use of medicines in clinical practice.

METHODS: Relevant literature was identified by performing MEDLINE/Pubmed searches covering the period from 1988 to 2006.

RESULTS: Seven classes of drugs were chosen, including gastric proton pump inhibitors, histamine H₂-receptor antagonists, benzamide-type gastroprokinetic agents, selective 5-HT₃ receptor antagonists, fluoroquinolones, macrolide antibiotics and azole antifungals. They showed significant differences in metabolic profile (i.e., the fraction of drug metabolized by cytochrome P450 (CYP), CYP reaction phenotype, impact of CYP genotype on interindividual pharmacokinetics variability and CYP-mediated drug-drug interaction potential). Many events of severe adverse drug reactions and treatment failures were closely related to the ignorance of the above issues.

CONCLUSION: Clinicians should acquaint themselves with what kind of drug has less interpatient variability in clearance and whether to perform CYP genotyping prior to initiation of therapy. The relevant CYP knowledge helps clinicians to enhance the management of patients with gastrointestinal disease who may require treatment with polytherapeutic regimens.

Low efficacy rate of moxifloxacin-containing Helicobacter pylori eradication treatment: in an observational study in a Turkish population

BACKGROUND

Standard triple therapy for Helicobacter pylori has an eradication rate of about 50% in Turkey. It may be due to an increased resistance of H. pylori to antibiotics. Therefore, we aimed to investigate the effectiveness of a new second-generation fluoroquinolone, moxifloxacin-containing triple therapy in H. pylori eradication.

MATERIAL AND METHODS

This is an open-label, prospective, single-center, pilot study. We studied 71 dyspeptic patients infected with H. pylori diagnosed by both histology and rapid urease test. Out of 71 dyspeptic patients, 64 had non-ulcer dyspepsia and seven had peptic ulcer. Patients received pantoprazole (40 mg b.i.d.) plus moxifloxacin (400 mg/day) and amoxicillin (1000 mg b.i.d.) for 14 days. Eradication was assessed 4 weeks after completing the therapy by histology and rapid urease test. Per-protocol and intention-to-treat eradication rates were determined.

RESULTS

The eradication rate was 42.2% for the intention-to-treat analysis and 47.6% for the per-protocol analysis. Of all patients included in the study, 29.5% had side-effects and only 2.8% of the patients discontinued the treatment because of side-effects. Most of the complications were mild and self-limiting.

CONCLUSION

Triple therapy with pantoprazole, moxifloxacin, and amoxicillin for 14 days yielded unacceptably low eradication rates. However, using tests of susceptibility to antibiotics, further studies with larger sample sizes are needed to judge these eradication rates of moxifloxacin containing eradication treatment.

Treatment of Helicobacter pylori

Since the discovery of Helicobacter pylori in the early 1980s many treatment regimes have been developed to effectively treat this infection. International guidelines have allowed consensus on the best management and improved eradication rates. In recent years, increasing antimicrobial resistance has resulted in falling eradication rates with standard therapies. In this article, we review the most recent studies and guidelines in the treatment of H. pylori. Currently, the first-line treatment remains clarithromycin, amoxicillin or metronidazole and proton pump inhibitor twice daily, but a number of recent studies have shown low eradication rates with this treatment. Increased duration of therapy has been recommended to overcome the falling eradication rates. However, conflicting findings have been reported on the benefits of extending the length of traditional therapy. Sequential therapy may be an effective alternative to standard triple therapy in regions of increased antimicrobial resistance. Probiotics reduce side-effects from traditional regimens and may improve eradication rates. A quinolone-based second-line triple therapy appears to be effective and well tolerated. Bismuth-based quadruple therapy is also an effective alternative if available. In the future, regional antimicrobial resistance and eradication rates will determine the best treatment for H. pylori.

Helicobacter pylori: testing and treatment

Helicobacter pylori is an important pathogen worldwide. Accurate diagnosis and appropriate therapy is important in clinical practice. Invasive tests that accurately identify current infection include the biopsy urease test and histology. The best noninvasive tests for diagnosis include the urea breath test and stool antigen testing. Proton pump inhibitor therapy can lead to false-negative H. pylori test results, and treatment should be stopped for 1-2 weeks prior to testing if possible. In the setting of bleeding peptic ulcer disease, urea breath testing is recommended to rule out a false-negative biopsy test result if needed. The current recommendations for when to test for H. pylori vary around the world. Well-accepted indications include active and past ulcer disease, and gastric-mucosa associated lymphoid tissue lymphoma. There is no universal agreement regarding whether all patients with functional dyspepsia should be tested and treated, although this is an evidence-based recommendation. There is also evidence that H. pylori eradication prevents peptic ulcer disease in those starting NSAIDs long term. Primary treatment remains triple therapy with 10-14 days probably being superior to shorter courses of therapy. Quadruple therapy is recommended if standard triple therapy fails. Salvage therapies with levofloxacin, rifabutin or furazolidone have been identified. Novel approaches to treatment include sequential therapy and use of adjuvants.

Levofloxacin-containing triple therapy to eradicate the persistent H. pylori after a failed conventional triple therapy

OBJECTIVE

To identify the optimal dosage of levofloxacin to eradicate persistent Helicobacter pylori when triple therapy with amoxicillin, clarithromycin, and omeprazole fails.

METHODS

We investigated 124 patients whose triple therapy including clarithromycin had failed. Clarithromycin resistance was indirectly assessed by the (13)C-urea breath test, with a post-treatment value cut-off point at 15. All patients were randomly divided into two groups, to receive 1-week amoxicillin 1 g and lansoprazole 30 mg twice daily, plus either levofloxacin 500 mg once (ALL-500 group) or twice daily (ALL-1000 group). Six weeks later, the (13)C-urea breath test was repeated to assess whether H. pylori was eradicated.

RESULTS

Intention-to-treat (ITT) and per-protocol (PP) analysis showed no difference in H. pylori eradication rates in both the ALL-500 and ALL-1000 groups (ITT: 79% vs. 80.6%, p > .05; PP: 86% vs. 87.5%, p > .05). For both groups, the per-protocol H. pylori eradication rates were also similarly high between patients with a post-treatment value of (13)C-urea breath test < or = 15 and those with a value > 15 (ALL-500: 85% vs. 86.5%, p > .05; ALL-1000: 88.9% vs. 86.8%, p > .05).

CONCLUSION

One-week levofloxacin 500 mg daily-based triple therapy is effective for eradicating the persistent H. pylori after a failed triple therapy with amoxicillin, clarithromycin, and omeprazole.