Levofloxacin or Clarithromycin-based quadruple regimens: what is the best alternative as first-line treatment for Helicobacter pylori eradication in a country with high resistance rates for both antibiotics?

Synthesis and characterization of amoxicillin-loaded polymeric nanocapsules as a drug delivery system targeting Helicobacter pylori

BACKGROUND AND STUDY AIMS

Helicobacter pylori (H. pylori) is well known as the main cause of gastritis, gastroduodenal ulcers, gastric mucosa-associated lymphoid tissue lymphoma, and gastric cancer. Approximately 50% of the world's population is infected with H. pylori. In Egypt, a high prevalence of H. pylori infections has been reported in the general population. This study aimed to prepare amoxicillin-loaded poly (ɛ-caprolactone) nanocapsules to increase its gastric stability and therapeutic activity of the molecule against H. pylori.

MATERIALS AND METHODS

In this study, we used the water-oil-water double-emulsion technique to prepare spherical-shaped polymeric nanocapsules containing amoxicillin trihydrate as the core substance and biodegradable biocompatible poly (ɛ-caprolactone) as the shell material.

RESULTS

The encapsulation efficiency obtained was 97.2% ± 0.8%. The hydrodynamic diameter of the prepared nanocapsules was 287 ± 8 nm with a positive zeta potential. In vitro release studies indicated that the polymeric nanocapsules showed decreased release percentages at pH 1.2, simulating the gastric fluid while relatively increased release at pH 7.0 where the H. pylori reside. The in vitro antibacterial assay showed better efficiency for amoxicillin nanocapsules than for the uncapsulated free amoxicillin, no efficiency was detected for the PCL nanocapsules indicated that the antibacterial due to amoxicillin alone. Cytotoxicity studies demonstrated less cytotoxicity for the polymeric nanocapsules in comparison with amoxicillin.

CONCLUSIONS

In conclusion, we have demonstrated that biodegradable polymeric nanocapsules are useful drug delivery agents for increasing the gastric stability and therapeutic activity of amoxicillin trihydrate against H. pylori.

Comparison between Hybrid, Reverse Hybrid, and Non-Bismuth Levofloxacin Quadruple Regimens for Helicobacter Pylori Infection in Egypt: A Randomized Trial

BACKGROUND The prevalence of Helicobacter pylori (H. pylori) in developing countries is 50.8%, with the highest occurrence presented in Africa (79.1%). It increases the risk of chronic gastritis, peptic ulcer, cancer of the stomach, and lymphoma. The effect of standard treatment for H. pylori eradication is below 80%, and evaluation of alternative lines of treatment is needed. We aimed to compare the hybrid, reverse hybrid, and levofloxacin quadruple therapies as first-line therapy in Egypt. METHODS This was a randomized interventional trial done in the clinics affiliated with the Internal Medicine Department. 330 individuals were selected according to the inclusion criteria. They were divided into three groups: group 1 (110 subjects who received a reverse hybrid regimen), group 2 (110 subjects who received a hybrid regimen), and group 3 (110 subjects who received a non-bismuth levofloxacin quadruple regimen). RESULTS Group 3 had a significantly lower eradication rate of 82.7% versus 92.7% and 91.8% in groups 1 and 2, respectively. There were non-significant differences in the incidence rates of adverse events among the three groups. CONCLUSION Both the reverse hybrid and hybrid groups had good eradication rates in the Egyptian population, but non-bismuth levofloxacin quadruple therapy did not obtain a sufficient eradication rate.

Efficacy of bismuth-based quadruple therapy for eradication of Helicobacter pylori infection based on previous antibiotic exposure: A large-scale prospective, single-center clinical trial in China

OBJECTIVE

This study aims to evaluate the efficacy and safety of three bismuth-based quadruple regimens for eradication of Helicobacter pylori (H pylori) infection in a large number of H pylori-positive patients with or without previous eradication therapy.

METHODS

Consecutive adult patients with H pylori infection, regardless of previous eradication therapy, were eligible for the present study. Three bismuth-based quadruple regimens were selected according to the past history of antibiotics use: (A) esomeprazole, amoxicillin, clarithromycin, and colloidal bismuth tartrate; (B) esomeprazole, amoxicillin, furazolidone, and colloidal bismuth tartrate; and (C) esomeprazole, doxycycline, furazolidone, and colloidal bismuth tartrate. All patients received a 14-day course of treatment, and ¹³ C/¹⁴ C urea breath test was utilized at four weeks after the completion of treatment to determine the H pylori eradication. Then, the eradication rates were calculated in terms of intention-to-treat (ITT) and per-protocol (PP) analyses. Adverse events (AEs) were recorded during the treatment.

RESULTS

Overall, 1,226 patients were recruited, and 331, 57, and 838 patients were allocated to receive regimens A, B, and C, respectively. The H pylori eradication rates were 84.0%, 82.5%, and 82.9% (ITT) and 94.6%, 92.2%, and 93.7% (PP), respectively, in regimens A, B, and C. However, there was no significant difference among these three regimens. The incidence of AEs was 4.6% for all patients during the study, that is, 3.3%, 10.5%, and 4.7% for regimens A, B, and C, respectively. All AEs were mild and recovered at the follow-up visit.

CONCLUSION

All three bismuth-based quadruple regimens based on the previous antibiotic use can achieve satisfactory eradication rates for H pylori infection and are safe.

Treatment of Helicobacter pylori infection 2017

This review summarizes important studies regarding Helicobacter pylori therapy published from April 2016 to April 2017. The main themes that emerge involve studies assessing the efficacy of bismuth and nonbismuth quadruple regimens. While in recent years, much of the emphasis on the use of bismuth has focussed on its utility in a second-line setting, an increasing number of studies this year have shown excellent efficacy in first-line therapy. The efficacy of bismuth as a second-line after sequential and concomitant therapy was particularly noteworthy. Antibiotic resistance was more intensely studied this year than for a long time, and definite trends are presented regarding an increase in resistance, including the fact that clarithromycin resistance in particular is now at a level where the continued use of clarithromycin triple therapy first-line as a mainstream treatment is not recommended. Another exciting trend to emerge this year is the utility of vonoprazan as an alternative to PPI therapy, especially in resistant and difficult-to-treat groups.

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

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