Update on non-bismuth quadruple (concomitant) therapy for eradication of Helicobacter pylori

Oral Hygiene With Neutral Electrolyzed Water and Systemic Therapy Increases Gastric Helicobacter pylori Eradication and Reduces Recurrence

OBJECTIVES

Helicobacter pylori gastric infection strongly correlates with gastric diseases such as chronic gastritis, functional dyspepsia, and complications such as peptic ulcers and gastric cancer. In developing countries, systemic therapies are not usually successful due to elevated antibiotic resistance. Additionally, oral H. pylori infection and periodontal disease correlate with gastric treatment failures. This study aimed to explore the effect of an integral therapy, comprising oral hygiene and concomitant systemic treatment, to increase the eradication of gastric infection and recurrences.

MATERIALS AND METHODS

A prospective, randomized, four-arm, parallel-group, open-label clinical trial was conducted to investigate the efficacy of integral therapy to eradicate gastric H. pylori infection and avoid recurrences in double-positive (real-time PCR oral and gastric infection) patients. Oral hygiene involved mouthwash with neutral electrolyzed water (NEW), with or without periodontal treatment. One hundred patients were equally distributed into four groups: NS, NS-PT, NEW, and NEW-PT. All patients had concomitant systemic therapy and additionally, the following oral treatments: mouthwash with normal saline (NS), periodontal treatment and mouthwash with normal saline (NS-PT), mouthwash with NEW (NEW), and periodontal treatment and mouthwash with NEW (NEW-PT). Gastric and oral infection and symptoms were evaluated one and four months after treatments.

RESULTS

Integral therapy with NEW-PT increased gastric eradication rates compared with NS or NS-PT (84%-96% vs. 20%-56%; p < 0.001). Even more, a protective effect of 81.2% (RR = 0.1877; 95% CI: 0.0658-0.5355; p = 0.0018) against recurrences and 76.6% (RR = 0.2439; 95% CI: 0.1380-0.4310; p < 0.001) against treatment failure (eradication of infection and associated symptoms) was observed in patients from the NEW and NEW-PT groups.

CONCLUSIONS

Implementation of oral hygiene and systemic treatment can increase the eradication of gastric infection, associated symptoms, and recurrences. NEW is recommended as an antiseptic mouthwash due to its efficacy and short- and long-term safety.

Sequential versus Standard Triple Therapy for First-Line Helicobacter pylori Eradication: An Update

BACKGROUND

non-bismuth sequential therapy (SEQ) was suggested as a first-line anti-Helicobacter pylori treatment alternative to standard triple therapy (STT).

METHODS

We conducted a systematic review with a meta-analysis of randomized controlled trials (RCTs) comparing the efficacy of 10-day SEQ vs. STT (of at least 7 days) using bibliographical searches up to July 2021, including treatment-naïve adult or children. The intention-to-treat (ITT) eradication rate and the risk difference (RD) were calculated.

RESULTS

Overall, 69 RCTs were evaluated, including 19,657 patients (9486 in SEQ; 10,171 in STT). Overall, SEQ was significantly more effective than STT (82% vs. 75%; RD 0.08; p < 0.001). The results were highly heterogeneous (I2 = 68%), and 38 studies did not demonstrate differences between therapies. Subgroup analyses suggested that patients with clarithromycin resistance only and all geographical areas but South America could benefit more from SEQ. Both therapies have evolved over the years, showing similar results when STT lasted 14 days; however, a tendency toward lower SEQ efficacy was noted from 2010 onwards.

CONCLUSIONS

Prior to 2010, SEQ was significantly more effective than STT, notably when 7-day STT was prescribed. A tendency toward lower differences between SEQ and STT has been noted, especially when using 10-day STT. None of the therapies achieved an optimal efficacy and therefore cannot be recommended as a valid first-line H. pylori treatment.

Helicobacter pylori: A Contemporary Perspective on Pathogenesis, Diagnosis and Treatment Strategies

Helicobacter pylori (H. pylori) is a Gram-negative bacterium that colonizes the gastric mucosa and is associated with various gastrointestinal disorders. H. pylori is a pervasive pathogen, infecting nearly 50% of the world's population, and presents a substantial concern due to its link with gastric cancer, ranking as the third most common cause of global cancer-related mortality. This review article provides an updated and comprehensive overview of the current understanding of H. pylori infection, focusing on its pathogenesis, diagnosis, and treatment strategies. The intricate mechanisms underlying its pathogenesis, including the virulence factors and host interactions, are discussed in detail. The diagnostic methods, ranging from the traditional techniques to the advanced molecular approaches, are explored, highlighting their strengths and limitations. The evolving landscape of treatment strategies, including antibiotic regimens and emerging therapeutic approaches, is thoroughly examined. Through a critical synthesis of the recent research findings, this article offers valuable insights into the contemporary knowledge of Helicobacter pylori infection, guiding both clinicians and researchers toward effective management and future directions in combating this global health challenge.

Updates to the Diagnosis and Clinical Management of Helicobacter pylori Infections

BACKGROUND

Helicobacter pylori (H. pylori) affects nearly half of the world's populations with high incidence and prevalence rates in developing countries. Infection with H. pylori increases the risk of developing peptic ulcer disease and gastric cancer. This review provides a summary of the prevalence and microbiology of H. pylori with emphasis on the current diagnostic methods and clinical management strategies.

CONTENT

This review discusses current options and developments in H. pylori diagnosis with the challenges and advantages associated with both noninvasive and invasive methods. The advantages of molecular methods for the diagnosis of H. pylori infection and prediction of clarithromycin resistance directly from stool or tissue biopsies are discussed. In addition, we provide a brief review on the treatment for H. pylori indicated in patients with evidence of active infection with the organism's antimicrobial resistance patterns taken into consideration.

SUMMARY

Testing for H. pylori has largely centered around fecal antigen testing, urea breath testing, and immunohistochemical staining from tissue biopsies. Culture-based diagnostics followed by phenotypic antimicrobial susceptibility testing is the gold standard for detection of resistance patterns. Due to the fastidious nature of the organism, culture methods are time consuming and labor intensive. Rapid nucleic acid amplification tests for H. pylori identification from direct specimens and molecular determination of drug resistance markers are accurate alternatives for H. pylori diagnosis but are not widely adopted. H. pylori antimicrobial resistance rates are on the rise due to the widespread use of antibiotics. Antibiotic regimens including the quadruple therapy and non-clarithromycin triple therapies have a higher success rate, with newer vonoprazon-based regimens showing promising eradication rates.

Update on the first-line treatment of Helicobacter pylori infection in areas with high and low clarithromycin resistances

Current international consensuses on Helicobacter pylori eradication therapy recommend that only regimens that reliably produce eradication rates of ⩾90% should be used for empirical treatment. The Real-world Practice & Expectation of Asia-Pacific Physicians and Patients in Helicobacter Pylori Eradication Survey also showed that the accepted minimal eradication rate in H. pylori-infected patients was 91%. According to efficacy prediction model, the per-protocol eradication rates of 7-day and 14-day standard triple therapies fall below 90% when clarithromycin resistance rate ⩾5%. Several strategies including bismuth-containing, non-bismuth-containing quadruple therapies (including sequential, concomitant, hybrid and reverse hybrid therapies), high-dose dual therapy and vonoprazan-based triple therapy have been proposed to increase the eradication rate of H. pylori infection. According to efficacy prediction model, the eradication rate of 14-day concomitant therapy, 14-day hybrid therapy and 7-day vonoprazan-based triple therapy is less than 90% if the frequency of clarithromycin-resistant strains is higher than 90%, 58% and 23%, respectively. To meet the recommendation of the consensus report and patients' expectation, local surveillance networks for resistance of H. pylori to clarithromycin are required to select appropriate eradication regimens in each geographic region. In areas with low (<5%) clarithromycin resistance (e.g. Sweden, Philippine, Myanmar and Bhutan), 7-day and 14-day standard triple therapies can be adopted for the first-line treatment of H. pylori infection with eradication rates of ⩾90%. In areas with high (⩾5%) clarithromycin resistance (most other countries worldwide) or unknown clarithromycin resistance, 14-day hybrid, 14-day reverse hybrid, 14-day concomitant and 10- to 14-day bismuth quadruple therapy can be used to treat H. pylori infection.

Empirical Second-Line Therapy in 5000 Patients of the European Registry on Helicobacter pylori Management (Hp-EuReg)

BACKGROUND & AIMS

After a first Helicobacter pylori eradication attempt, approximately 20% of patients will remain infected. The aim of the current study was to assess the effectiveness and safety of second-line empiric treatment in Europe.

METHODS

This international, multicenter, prospective, non-interventional registry aimed to evaluate the decisions and outcomes of H pylori management by European gastroenterologists. All infected adult cases with a previous eradication treatment attempt were registered with the Spanish Association of Gastroenterology-Research Electronic Data Capture until February 2021. Patients allergic to penicillin and those who received susceptibility-guided therapy were excluded. Data monitoring was performed to ensure data quality.

RESULTS

Overall, 5055 patients received empiric second-line treatment. Triple therapy with amoxicillin and levofloxacin was prescribed most commonly (33%). The overall effectiveness was 82% by modified intention-to-treat analysis and 83% in the per-protocol population. After failure of first-line clarithromycin-containing treatment, optimal eradication (&gt;90%) was obtained with moxifloxacin-containing triple therapy or levofloxacin-containing quadruple therapy (with bismuth). In patients receiving triple therapy containing levofloxacin or moxifloxacin, and levofloxacin-bismuth quadruple treatment, cure rates were optimized with 14-day regimens using high doses of proton pump inhibitors. However, 3-in-1 single capsule or levofloxacin-bismuth quadruple therapy produced reliable eradication rates regardless of proton pump inhibitor dose, duration of therapy, or previous first-line treatment. The overall incidence of adverse events was 28%, and most (85%) were mild. Three patients developed serious adverse events (0.3%) requiring hospitalization.

CONCLUSIONS

Empiric second-line regimens including 14-day quinolone triple therapies, 14-day levofloxacin-bismuth quadruple therapy, 14-day tetracycline-bismuth classic quadruple therapy, and 10-day bismuth quadruple therapy (as a single capsule) provided optimal effectiveness. However, many other second-line treatments evaluated reported low eradication rates. ClincialTrials.gov number: NCT02328131.

The Challenges of Eradicating Pediatric Helicobacter pylori Infection in the Era of Probiotics

Helicobacter pylori (H. pylori), the most common infection of childhood, results in life-threatening complications during adulthood if left untreated. Most of these complications are related to H. pylori-induced chronic inflammation. The dysbiosis caused by H. pylori is not limited to the gastric microenvironment, but it affects the entire gastrointestinal tract. Eradication of H. pylori has recently become a real challenge for clinicians due to both the persistent increase in antibiotic resistance worldwide and the wide spectrum of side effects associated with the eradication regimens resulting; therefore, there is an urgent need for more effective and less noxious treatment options. Thus, probiotics might be a promising choice in both adults and children with H. pylori infection since their role in improving the eradication rate of this infection has been proved in multiple studies. The positive effects of probiotics might be explained by their abilities to produce antimicrobial compounds and antioxidants, alter local gastric pH, and subsequently decrease H. pylori colonization and adherence to gastric epithelial cells. Nevertheless, if used alone probiotics do not considerably increase the eradication rate.

V Spanish Consensus Conference on Helicobacter pylori infection treatment

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

A randomized clinical trial comparing triple therapy versus non-bismuth based quadruple therapy for the eradication of Helicobacter Pylori in Kuwait

Introduction:

Helicobacter pylori-induced chronic infection is associated with peptic ulcer, chronic gastritis, gastric cancer, and increasing antibiotic resistance. We aimed to evaluate the efficacy of clarithromycin-based triple therapy and non-bismuth based quadruple therapy for eradicating H. pylori in patients with chronic gastritis in Kuwait.

Methods:

We enrolled a total of 603 treatment-naive dyspeptic patients with gastric biopsy-proven chronic gastritis secondary to H. pylori in a prospective, open-label, randomized study. Patients were randomized into two groups: a group received the standard triple therapy (omeprazole, amoxicillin, and clarithromycin) for 14 days and a group received quadruple therapy (omeprazole, amoxicillin, clarithromycin, and metronidazole) for 14 days. All patients were tested for the eradication of H. pylori by carbon-13 urea breath test 1 month after eradication therapy.

Results:

The overall eradication rate was 63.2%. The eradication rates in intention-to-treat (ITT) and per protocol (PP) population were 58.4% and 64.6%, respectively, in triple therapy group. In the quadruple therapy group, the eradication rates in ITT and PP population were 68.0% and 78.5%, respectively, with a statistically significant higher eradication rate in patients treated by quadruple therapy than the triple therapy (P < 0.01). Multivariate logistic regression analysis revealed that treatment regimen was the only significant predictor for successful H. pylori eradication. The most common adverse events were abnormal taste, headache, dizziness, and abdominal pain.

Conclusion:

Non-bismuth based quadruple therapy is more effective than standard clarithromycin-based triple therapy for eradicating H. pylori in patients with chronic gastritis.

ClinicalTrials.gov Identifier: NCT04617613

Revisiting Therapeutic Strategies for H. pylori Treatment in the Context of Antibiotic Resistance: Focus on Alternative and Complementary Therapies

The prevalence of Helicobacter pylori infection remains significant worldwide and it depends on many factors: gender, age, socio-economic status, geographic area, diet, and lifestyle. All successful infectious diseases treatments use antibiotic-susceptibility testing, but this strategy is not currently practical for H. pylori and the usual cure rates of H. pylori are lower than other bacterial infections. Actually, there is no treatment that ensures complete eradication of this pathogen. In the context of an alarming increase in resistance to antibiotics (especially to clarithromycin and metronidazole), alternative and complementary options and strategies are taken into consideration. As the success of antibacterial therapy depends not only on the susceptibility to given drugs, but also on the specific doses, formulations, use of adjuvants, treatment duration, and reinfection rates, this review discusses the current therapies for H. pylori treatment along with their advantages and limitations. As an alternative option, this work offers an extensively referenced approach on natural medicines against H. pylori, including the significance of nanotechnology in developing new strategies for treatment of H. pylori infection.

Helicobacter pylori infection and antibiotic resistance - from biology to clinical implications

Helicobacter pylori is a major human pathogen for which increasing antibiotic resistance constitutes a serious threat to human health. Molecular mechanisms underlying this resistance have been intensively studied and are discussed in this Review. Three profiles of resistance - single drug resistance, multidrug resistance and heteroresistance - seem to occur, probably with overlapping fundamental mechanisms and clinical implications. The mechanisms that have been most studied are related to mutational changes encoded chromosomally and disrupt the cellular activity of antibiotics through target-mediated mechanisms. Other biological attributes driving drug resistance in H. pylori have been less explored and this could imply more complex physiological changes (such as impaired regulation of drug uptake and/or efflux, or biofilm and coccoid formation) that remain largely elusive. Resistance-related attributes deployed by the pathogen cause treatment failures, diagnostic difficulties and ambiguity in clinical interpretation of therapeutic outcomes. Subsequent to the increasing antibiotic resistance, a substantial drop in H. pylori treatment efficacy has been noted globally. In the absence of an efficient vaccine, enhanced efforts are needed for setting new treatment strategies and for a better understanding of the emergence and spread of drug-resistant bacteria, as well as for improving diagnostic tools that can help optimize current antimicrobial regimens.

Randomized Clinical Trial Comparing Concomitant and Tailored Therapy for Eradication of Helicobacter pylori Infection

As high clarithromycin resistance (>20%) in the Split-Dalmatia region of Croatia hinders the treatment of H. pylori infection, the primary objective of this study was to compare concomitant quadruple with the tailored, personalized therapy as first-line eradication treatment of H. pylori. In an open-label, randomized clinical trial, 80 patients with H. pylori infection were randomly assigned to either concomitant (esomeprazole 40 mg, amoxicillin 1 gr, metronidazole 500 mg, clarithromycin 500 mg, twice daily for 14 days) or tailored therapy in accordance with the results of the antimicrobial susceptibility testing. Eradication status was assessed 4 weeks after treatment. Eradication rates were significantly higher in tailored group than in concomitant group both in intention-to-treat (70 vs. 92.5%, p = 0.010) and per-protocol (87.5 vs. 100%, p = 0.030) analysis in the setting of increasing antibiotic resistance (clarithromycin 37.5%, metronidazole 17.5%, dual resistance 10%). Adverse effects were more frequent in the concomitant group (32.5 vs. 7.5%, p = 0.006). Tailored therapy achieves higher eradication with a lower adverse events rate. With the increasing resistance of H. pylori strains to antibiotic treatment, eradication regimes with such characteristics should be strongly considered as a reasonable choice for first-line treatment.

Helicobacter pylori and association between its positivity and anatomotopographic settlement in the stomach with the host age range

Helicobacter pylori (H. pylori) is a Gram-negative, helically shaped flagellated bacterium. Major diseases associated with H. pylori infection include peptic ulcer, gastric adenocarcinoma, and mucosa-associated lymphoid tissue lymphoma. The incidence of H. pylori in the anatomotopographic regions of the stomach, such as antrum, corpus, fundus, and incisura angularis, has been investigated. Do the rates of H. pylori in the settlements change over time according to the age ranges of the hosts? Does this change affect the diseases caused by or related to H. pylori? It is estimated that the outcomes, which have been obtained, may provide a new perspective in terms of understanding the etiopathogenesis of H. pylori-induced diseases. A comprehensive literature search of PubMed/MEDLINE databases had been conducted using a combination of terms, “Helicobacter pylori,” “Sydney System,” “stomach,” “pyloric antrum,” “gastric corpus,” “stomach cancer,” and “Helicobacter pylori and age.” There are very few articles examining the relationship between the topographic locations of H. pylori and host age range in the English language literature. Therefore, it is also purposed to emphasize the outcomes of our current research about the mentioned topic. In our opinion, similar studies should reveal the settlement and age range in the different geographic locations and societies as in our study. We believe that these findings will contribute to the efforts for understanding overtly of H. pylori-induced disease of the stomach.

Best Helicobacter pylori Eradication Strategy in the Era of Antibiotic Resistance

Antibiotic resistance is the major reason for Helicobacter pylori treatment failure, and the increasing frequency of antibiotic resistance is a challenge for clinicians. Resistance to clarithromycin and metronidazole is a particular problem. The standard triple therapy (proton pump inhibitor, amoxicillin, and clarithromycin) is no longer appropriate as the first-line treatment in most areas. Recent guidelines for the treatment of H. pylori infection recommend a quadruple regimen (bismuth or non-bismuth) as the first-line therapy. This treatment strategy is effective for areas with high resistance to clarithromycin or metronidazole, but the resistance rate inevitably increases as a result of prolonged therapy with multiple antibiotics. Novel potassium-competitive acid blocker-based therapy may be effective, but the data are limited. Tailored therapy based on antimicrobial susceptibility test results is ideal. This review discussed the current important regimens for H. pylori treatment and the optimum H. pylori eradication strategy.

Helicobacter pylori: A Review of Current Diagnostic and Management Strategies

As one of the most prevalent infections globally, Helicobacter pylori (H. pylori) continues to present diagnostic and therapeutic challenges for clinicians worldwide. Diagnostically, the "test-and-treat" strategy is the recommended approach for healthcare practitioners when managing this potentially curable disease. The choice of testing method should be based on several factors including patient age, presenting symptoms, and medication use, as well as test reliability, availability, and cost. With rising antibiotic resistance, particularly of macrolides, care must be taken to ensure that therapy is selected based on regional resistance patterns and prior antibiotic exposure. In the USA, macrolide antibiotic resistance rates in some areas have reached or exceeded a generally accepted threshold, such that clarithromycin triple therapy may no longer be an appropriate first-line empiric treatment. Instead, bismuth quadruple therapy should be considered, while levofloxacin-based or alternative macrolide-containing therapies are also options. Once treated, it is essential to test for eradication as untreated H. pylori is associated with serious complications including peptic ulcer disease, mucosa-associated lymphoid tissue lymphoma, and gastric cancer. This review article aims to consolidate current knowledge of H. pylori infection with a particular emphasis on diagnostic and treatment strategies.

Treatment strategies and preventive methods for drug-resistant Helicobacter pylori infection

The infection and drug resistance rates of Helicobacter pylori (H. pylori) are high and must be prevented and treated by better strategies. Based on recent research advances in this field as well as the results from our team and those on traditional Chinese medicine, we review the causes of drug resistance, and prevention and treatment strategies for drug-resistant H. pylori infection, with an aim to make suggestions for the development of new drugs, such as establishment of new target identification and screening systems, modification of existing drug structures, use of new technologies, application of natural products, and using a commercial compound library. This article may provide reference for eradication of drug-resistant H. pylori.

Comparison of four different regimens against Helicobacter pylori as a first-line treatment: A prospective, cross-sectional, comparative, open trial in Chinese children

BACKGROUNDS

Due to the decreasing eradication rate of Helicobacter pylori, some novel alternatives have been developed, such as bismuth-containing quadruple therapy and non-bismuth-containing quadruple therapy (sequential and concomitant treatment). Little is known about whether a success rate above 90% can be achieved with these regimens in Chinese children.

METHODS

In this prospective, open, comparative cross-sectional study, we recruited treatment-naïve children (aged between 6 and 18 years) with H pylori infection. The patients were assigned either standard triple therapy, sequential therapy, bismuth-based quadruple therapy, or concomitant therapy at the discretion of the prescribing physician. H pylori infection was evaluated at least 4 weeks after the completion of the treatment. A negative urea breath test (UBT) indicated successful eradication. The primary endpoint was the eradication frequency of H pylori in the full analysis set (FAS), which included all children who received at least one dose of the treatment and with available follow-up data.

RESULTS

Between September 2017 and December 2018, 228 patients were finally included in the FAS analyses. The eradication rates were 74.1% for standard triple therapy (43/58, [95% CI: 62.8%-85.5%]), 69.5% for sequential therapy (41/59, [95% CI: 57.8%-81.2%]), 89.8% for bismuth-based quadruple therapy (53/59, [95% CI: 82.1%-97.5%]), and 84.6% for concomitant therapy (44/52, [95% CI: 74.8%-94.4%]). Bismuth-based therapy was superior to triple therapy, while sequential therapy and concomitant therapy were not superior to triple therapy. The frequency of adverse events was 12.1% (7/58) in standard triple therapy, 6.8% (4/59) in sequential therapy, 15.3% (9/59) in bismuth-based therapy, and 15.4% (8/52) in concomitant therapy. The rate of adverse events was similar among the four groups.

CONCLUSION

Bismuth quadruple therapy can achieve an eradication rate of 89.8% as first-line treatment and is safe and well tolerated. Bismuth could be a promising alternative as a first-line regimen in Chinese children.

Synergistic Effect of Rubus crataegifolius and Ulmus macrocarpa Against Helicobacter pylori Clinical Isolates and Gastritis

Helicobacter pylori is one of the most widespread infections involved in the pathogenesis of chronic gastritis, peptic ulcer, and gastric cancer. Hence, there is an urgent need to develop medications against H. pylori. This study aimed to evaluate synergistic effect of Rubus crataegifolius (RF) and Ulmus macrocarpa Hance (UL) against H. pylori. Antibacterial susceptibility of each extract either separately or in combination was studied against two H. pylori standard strains and 11 clinical isolates using agar dilution method. The effect of the extracts on H. pylori inoculated Balb/c mice model was also studied using single dosing (100 mg/kg each) approach. The MIC₅₀ of RF and UL were more than 100 and 200 µg/ml, respectively, against the tested strains. However, simultaneous treatment with RF and UL at 75 and 50 µg/ml, respectively, showed decreased viable cell number, MIC₇₀, and at 75 µg/ml each showed synergic effect with MIC₉₀. On H. pylori inoculated Balb/c mice model, RF and UL separately (100 mg/kg each) showed moderate anti-H. pylori effect, while simultaneous treatment of RF and UL with same dose showed significant synergistic anti-gastric effects in stomach. The results showed a significant synergistic effect of plants extract against H. pylori infection and eventually gastric mucosal damage. Our finding could be considered a valuable support in the treatment of H. pylori induced gastritis and may contribute to the development of new and safe combined herbal product as anti-H. pylori regimens.

Hellenic consensus on Helicobacter pylori infection

The Hellenic Society of Gastroenterology recently organized the “Hellenic consensus on Helicobacter pylori (H. pylori) infection”. The aim of this publication is to report the guidelines in order to aid the national gastroenterology community in the management of H. pylori infection. Forty-one delegates from all Greek regions, including gastroenterologists, pathologists, clinical microbiologists, epidemiologists and basic scientists, were invited to this meeting. The participants were allocated to 1 of the 4 main topics of the meeting: i.e., H. pylori diagnosis and association with diseases; H. pylori and gastric cancer; H. pylori and extragastric associated disorders; and H. pylori treatment. The results of each subgroup were submitted to a final consensus vote that included all participants. Relevant data based on international and Greek publications were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded. The cutoff level of 70% was considered as acceptance for the final statement. It is hoped that the recommendations and conclusions of this report will guide Greek doctors in their daily practice concerning the management of H. pylori infection.

Optimal duration of concomitant nonbismuth quadruple therapy as first-line therapy for Helicobacter pylori: a prospective, open-label, comparative study

BACKGROUND

Concomitant nonbismuth quadruple therapy is recommended as first-line treatment for Helicobacter pylori infection in high clarithromycin resistance areas, but the ideal duration of the regimen remains elusive. Aim of this study was to assess the efficacy and tolerability of 10- versus 14-day concomitant therapy for H. pylori eradication in an area of high clarithromycin and low dual clarithromycin/metronidazole resistance.

METHODS

This was a prospective, open-label study including adult patients with H. pylori infection without previous treatment, from September 2014 to June 2017. Concomitant therapy consisting of pantoprazole 40 mg, amoxicillin 1g, clarithromycin 500 mg, and a nitroimidazole 500 mg was administered twice daily for 10 days in the first phase and for 14 days in the second phase of the study. Efficacy and side effects were compared between groups using chi-square and Fisher's exact tests.

RESULTS

In per protocol analysis, rates of eradication for the 10- and 14-day regimen were 91.9% (114/124) and 90.9% (110/121), respectively (P = 0.77). In intention to treat analysis, rates of eradication were lower than 90%. Specifically, rates were 86.3% (114/132) for the 10-day regimen and 85.2% (110/129) for the 14-day regimen (P = 0.8). Side effects, present in 31.3% of treated patients, were significantly more common in the 14-day group (P = 0.015). Four patients discontinued treatment, all in the 14-day group.

CONCLUSIONS

Ten day concomitant nonbismuth quadruple therapy for H. pylori is highly efficacious and better tolerated than the 14-day regimen. Thus, 10-day therapy may be preferred as first-line treatment in clinical practice.

[The efficacy and safety of quadruple therapy without bismuth (concomitant therapy) in the treatment of patients with Helicobacter pylori - associated gastric and duodenal peptic ulcer disease]

AIM

Evaluation of the efficacy and safety of quadrupletherapy without bismuth (concomitant therapy) in patients with Helicobacter pylori - associated gastric ulcer and duodenal ulcer in the framework of a comparative research in the population of patients in Russia.

MATERIALS AND METHODS

A prospective randomized trial was conducted, which included 210 patients with H. pylori - associated gastric/duodenal ulcer without complications. During the process of randomization, the patients were divided into three equal groups (n=70) depending on the prescribed 10-day scheme of eradication therapy (ET): the first group received the classic triple scheme (Omeprazole 20 mg 2 times a day, Amoxicillin 1000 mg 2 times a day and Clarithromycin 500 mg 2 times a day); the second group received quadruple therapy with bismuth drugs (Omeprazole 20 mg 2 times a day, Tetracycline 500 mg 4 times a day, Metronidazole 500 mg 3 times a day, Bismuth subcitrate potassium 120 mg 4 times a day); the third group received quadruple therapy without bismuth - concomitant therapy (Omeprazole 20 mg 2 times a day, Amoxicillin 1000 mg 2 times a day, Clarithromycin 500 mg 2 times a day and Metronidazole 500 mg 2 times a day). Diagnostics of H. pylori infection during screening and control of eradication was carried out via the fast urease biopsy sample test and urea breath test system. Control of the effectiveness of ET of the microorganism was carried out not earlier than 4 weeks after the end of the treatment. During the course of therapy, the frequency of development of side effects was assessed using a special questionnaire.

RESULTS AND DISCUSSION

The effectiveness of triple therapy was 72.8% (ITT; 95% CI of 62.17-83.54) and 78,4% (PP; 95% CI 68.19-88.72); quadruple therapy with the preparation of bismuth - 80.0% (ITT; 95% CI 70.39-89.6) and 84,8% (PP; 95% CI, 75.96-93.73); quadruple therapy without bismuth - concomitant therapy - 84.2% (ITT; 95% CI 75.54-93.02) and 92.1% (PP; 95% CI 85.43-98.94). Quadruple therapy without bismuth was reliably more effective than the classical triple therapy in the PP selection (p=0.044883). Statistical analysis showed a tendency to poorer effectiveness of ET in patients who had previously used antibiotic therapy (OR 0.4317; 95% CI 0.1776-1.049), and in individuals with a rapid metabolism genotype - CYP2C19*1/*1 (OR 0.12; 95% CI 0.005848-2.4624). The frequency of development of side effects during the use of triple therapy was 18.5% (95% CI of 9.23-27.91), when using quadruple therapy with bismuth - 20.0% (95% CI 10.39-29.6), and with the use of quadruple therapy without bismuth - concomitant therapy - 24.2% (95% CI 13.98-34.58).

CONCLUSION

This prospective randomized study demonstrated the high efficiency of quadruple therapy without bismuth (concomitant therapy) in the framework of eradication of H. pylori infection in Russia.

Systematic Review with Meta-Analysis: Concomitant Therapy vs. Triple Therapy for the First-Line Treatment of Helicobacter pylori Infection

BACKGROUND

Whether concomitant therapy is superior to triple therapy of various treatment lengths for the first-line treatment of H. pylori remains controversial. The objective of this study is to compare the efficacy of concomitant therapy and triple therapy given for 5-14 days.

METHODS

Randomized control trials (RCTs) comparing the efficacy of concomitant therapy for 5-14 days and proton pump inhibitor-amoxicillin-clarithromycin (PAC)-based triple therapy for 5-14 days in the first-line treatment of adult patients with H. pylori infection published from 1990 to January 2018 were searched from the PubMed, Cochrane Library, and Embase. Abstracts from international annual conferences were also searched. The primary and secondary outcomes were the eradication rate according to the intention-to-treat analysis and the adverse effects, respectively. Subgroup analyses were also performed according to treatment length. This study is registered with PROSPERO, number CRD42017081328.

RESULTS

Of the 639 articles identified, 23 RCTs including 3305 patients in the concomitant therapy group and 3327 patients in the triple therapy group were eligible. Overall, concomitant therapy was superior to triple therapy [risk ratio (RR): 1.15; 95% confidence interval (CI): 1.09-1.21; p < 0.001]. However, there were significant heterogeneity (I² = 74.0%, p < 0.001). In the subgroup analysis, 5-day concomitant therapy was superior to 5-day triple therapy (RR: 1.30; 95% CI: 1.04-1.62; p = 0.02), 5- or 7-day concomitant therapy was superior to 7-day triple therapy (RR: 1.16; 95% CI: 1.12-1.21; p < 0.001), and 5- or 7-, or 10- or 14-day concomitant therapy was superior to 10-day triple therapy (RR: 1.15; 95% CI: 1.08-1.23; p < 0.001). However, 5- or 10-day concomitant therapy was not superior to 14-day triple therapy (RR: 1.02; 95% CI: 0.89-1.16; p = 0.796). The frequency of adverse effects was significantly higher in concomitant therapy than triple therapy (RR: 1.19; 95% CI: 1.06-1.34; P = 0.004).

CONCLUSIONS

Concomitant therapy given for 5 or 10 days was superior to 5- or 7-, or 10-day PAC-based triple therapy, but was not superior to 14-day triple therapy.

Understanding treatment guidelines with bismuth and non-bismuth quadruple Helicobacter pylori eradication therapies

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.

The fourth Mexican consensus on Helicobacter pylori

Important advances have been made since the last Mexican consensus on the diagnosis and treatment of Helicobacter pylori (H. pylori) infection was published in 2007. Therefore, the Asociación Mexicana de Gastroenterología summoned 20 experts to produce "The Fourth Mexican Consensus on Helicobacter pylori". From February to June 2017, 4 working groups were organized, a literature review was performed, and 3 voting rounds were carried out, resulting in the formulation of 32 statements for discussion and consensus. From the ensuing recommendations, it was striking that Mexico is a country with an intermediate-to-low risk for gastric cancer, despite having a high prevalence of H. pylori infection. It was also corroborated that peptic ulcer disease, premalignant lesions, and histories of gastric cancer and mucosa-associated lymphoid tissue lymphoma should be considered clear indications for eradication. The relation of H. pylori to dyspeptic symptoms continues to be controversial. Eradication triple therapy with amoxicillin, clarithromycin, and a proton pump inhibitor should no longer be considered first-line treatment, with the following 2 options proposed to take its place: quadruple therapy with bismuth (proton pump inhibitor, bismuth subcitrate, tetracycline, and metronidazole) and quadruple therapy without bismuth (proton pump inhibitor, amoxicillin, clarithromycin, and metronidazole). The need for antimicrobial sensitivity testing when 2 eradication treatments have failed was also established. Finally, the promotion of educational campaigns on the diagnosis and treatment of H. pylori for both primary care physicians and the general population were proposed.

Comparative study of Helicobacter pylori eradication rates of concomitant therapy vs modified quadruple therapy comprising proton-pump inhibitor, bismuth, amoxicillin, and metronidazole in Korea

BACKGROUND

The standard triple Helicobacter pylori regimen now shows unacceptably low treatment success in Korea. Administration of the concomitant therapy for 10 days, which has a high cure rate, is recommended as an alternative first-line treatment in areas of high clarithromycin resistance including Korea. Recently, modified bismuth-containing quadruple therapy with amoxicillin (PAM-B therapy) showed excellent results, regardless of dual clarithromycin and metronidazole resistance. This study compared the concomitant therapy with PAM-B therapy as a first-line treatment for H. pylori infection.

METHOD

Subjects infected with H. pylori and naïve to treatment were performed a head-to-head comparison between 10-day concomitant therapy [rabeprazole 20 mg, amoxicillin 1 g, clarithromycin 500 mg, and metronidazole 500 mg twice daily] and 14-day PAM-B therapy [rabeprazole 20 mg, amoxicillin 1 g, metronidazole 750 mg, and tripotassium dicitrato bismuthate 600 mg (elemental bismuth 240 mg) twice daily]. Six weeks after treatment, H. pylori eradication was assessed.

RESULTS

Two hundred and seventy subjects were randomized. Both regimens achieved high cure rates: 83.0% (112/135) and 88.1% (119/135) by the intention-to-treat analysis and 95.5% (106/111) and 96.6% (114/118) by the per-protocol analysis, respectively. The intention-to-treat and per-protocol analyses revealed no statistically significant difference in the eradication rate (P = .299 and P = .743, respectively). Rates of adverse events were similar between groups (25.2% vs 23.0%, P -value: .776) Adverse events, which resulted in poor compliance, occurred in six patients of each group, but there were no serious complications.

CONCLUSIONS

PAM-B therapy is as effective as concomitant therapy for eradicating H. pylori with comparative safety. PAM-B therapy is regarded as a promising alternative to standard triple therapy for a first-line eradication in Korea.

Dealing with uncertainty in the treatment of Helicobacter pylori

Helicobacter pylori treatment may be viewed as an uncertain situation, where current knowledge is insufficient to provide evidence-based recommendations for all possible scenarios. Evidence suggests that, under uncertainty conditions, a few simple rules of thumb tend to work better than complex algorithms. Overall, five evidence-based rules of thumb are suggested: (1) Use four drugs; (2) Use maximal acid inhibition; (3) Treat for 2 weeks; (4) Do not repeat antibiotics after treatment failure; and (5) If your treatment works locally, keep using it. These simple rules of thumb may help the reader to select the best alternative for a given patient, choosing between the heterogeneous recommendations provided by the many different consensus conferences on H. pylori treatment recently published.

First-line Helicobacter pylori eradication therapies in countries with high and low clarithromycin resistance: a systematic review and network meta-analysis

OBJECTIVE

To determine the optimal regimen of different first-line Helicobacter pylori eradication therapies according to the clarithromycin resistance rate.

DESIGN

Electronic search for articles published between January 2005 and April 2016. Randomised, controlled trials that reported the effectiveness of first-line eradication therapies in treatment-naïve adults were included. Two independent reviewers performed articles screening and data extraction. Network and traditional meta-analyses were conducted using the random effect model. Subgroup analyses were performed to determine the ranking of regimens in countries with high (>15%) and low (<15%) clarithromycin resistance. Data including adverse events and therapeutic cure rate were also extracted and analysed.

RESULTS

117 trials (totally 32 852 patients) for 17 H. pylori eradication regimens were eligible for inclusion. Compared with 7-day clarithromycin-based triple therapy, sequential therapy (ST) for 14 days had the highest effectiveness (OR=3.74, 95% CrI 2.37 to 5.96). ST-14 (OR=6.53, 95% CrI 3.23 to 13.63) and hybrid therapy (HY) for 10 days or more (OR=2.85, 95% CrI 1.58 to 5.37) represented the most effective regimen in areas with high and low clarithromycin resistance, respectively. The effectiveness of standard triple therapy was below therapeutic eradication rate in most of the countries. Longer duration was associated with higher eradication rate, but with a higher risk of events that lead to discontinuation.

CONCLUSIONS

ST and HY appeared to be the most effective therapies in countries with high and low clarithromycin resistance, respectively. The clinical decision for optimal regimen can be supported by referring to the rank ordering of relative efficacies stratified by local eradication rates, antibiotic resistance and safety profile.

TRIAL REGISTRATION NUMBER

CRD42015025445.

Helicobacter pylori treatment: antibiotics or probiotics

Treatment of Helicobacter pylori infection is important for the management of gastrointestinal disorders such as peptic ulcer and gastric cancer. Due to the increase in the prevalence of H. pylori resistance to antibiotics, triple therapy with clarithromycin is no longer the best treatment for H. pylori, especially in some areas where the local resistance to this antibiotic is higher than 20%. Alternative treatments have been proposed for the eradication of H. pylori. Some of them including novel antibiotics or classical ones in different combinations; these treatments are being used in the regular clinical practice as novel and more effective treatments. Others therapies are using probiotics associated to antibiotics to treat this infection.The present article is a revision of H. pylori eradication treatment, focusing on emerging approaches to avoid the treatment failure, using new therapies with antimicrobials or with probiotics.

First-Line Helicobacter pylori Eradication in Patients with Chronic Kidney Diseases in Taiwan

Aims

Patients with chronic kidney disease (CKD) and Helicobacter pylori (H. pylori) infection have a higher incidence of gastroduodenal diseases and therefore are recommended to receive eradication therapies. This study aimed to assess the efficacy of a 7-day standard triple therapy in patients with CKD (eGFR < 60 ml/min/1.73 m²) and to investigate the clinical factors influencing the success of eradication.

Methods

A total of 758 patients with H. pylori infection receiving a 7-day standard first-line triple therapy between January 1, 2013, and December 31, 2014, were recruited. Patients were divided into two groups: CKD group (N = 130) and non-CKD group (N = 628).

Results

The eradication rates attained by the CKD and non-CKD groups were 85.4% and 85.7%, respectively, in the per-protocol analysis (p = 0.933). The eradication rate in CKD stage 3 was 84.5% (82/97), in stage 4 was 88.2% (15/17), and in those who received hemodialysis was 87.5% (14/16). There were no significant differences in the various stages of CKD (p = 0.982). The adverse events were similar between the two groups (3.1% versus 4.6%, p = 0.433). Compliance between the two groups was good (100.0% versus 99.8%, p = 0.649). There was no significant clinical factor influencing the H. pylori eradication rate in the non-CKD and CKD groups.

Conclusions

This study suggests that the H. pylori eradication rate and adverse rate in patients with CKD are comparable to those of non-CKD patients.

High primary antibiotic resistance of Helicobacter Pylori strains isolated from dyspeptic patients: A prevalence cross-sectional study in Spain

BACKGROUND

The rate of H. pylori resistance to different antibiotics is increasing and determines the selection of eradication therapy. The aim of this study was to determine the resistance patterns of H. pylori strains in our area.

METHODS

Biopsies from gastric corpus for microbiological culture and antibiotic resistance were obtained in patients undergoing upper gastrointestinal endoscopy for dyspepsia. Selective Agar Pylori for isolation of the bacteria and Agar Mueller-Hinton supplemented with blood to test the sensitivity to antibiotics were used. Presence of H. pylori was confirmed using direct observation with phase-contrast microscopy and/or smears stained with acridine orange. In vitro bacterial susceptibility to amoxicillin, clarithromycin, rifampicin, tetracycline, metronidazole, and levofloxacin was tested using diffusion MIC test strips. Minimum inhibitory concentration values were determined based on the 6th version of the EUCAST (European Committee on Antimicrobial Susceptibility Testing) Clinical Breakpoint (2016).

RESULTS

Two hundred and seventeen patients were included (58.1% female, median age 64 years, range 25-92). H. pylori was identified in 108 patients (49.8%); culture and antibiogram were completed in 77 of them (71.3% of H. pylori-positive patients). The resistance rates were as follows: levofloxacin 38.7%, rifampicin 33.3%, metronidazole 27% and clarithromycin 22.4%. No case of amoxicillin or tetracycline resistance was identified. Dual clarithromycin-metronidazole resistance was observed in 10% of strains, whereas multiple drug-resistant was observed in 14.2%.

CONCLUSIONS

Resistance rate of H. pylori to antibiotics is high in the northwest of Spain. The high resistance to levofloxacin and clarithromycin advises against their wide empirical use of these antibiotics in eradication regimens.

Eradication of Helicobacter Pylori in Iran: A Review

Helicobacter pylori (H. pylori) infection is one of the most common bacterial infections, affecting almost half of the world’s population. It is associated with peptic ulcer disease, gastric adenocarcinoma, and lymphoma. In Iran, the prevalence of H. pylori infection has been reported to be between 36% and 90% in different geographic regions.

Several studies have assessed the efficacy of different therapeutic options for firstline and second-line H. pylori eradication in Iran; however, the results are conflicting. Therefore, we conducted a review to evaluate different studies in order to select the best options and to provide recommendations for H. pylori eradication in Iran. Accordingly, we searched through PubMed to obtain relevant randomized clinical trials published in English language up to June 2017.

According to our study, among first-line eradication regimens, bismuth-based furazolidone- or clarithromycin-containing quadruple therapies, hybrid regimen, and concomitant therapy seem to be appropriate options. Also, 10- or 14-day clarithromycin-containing triple therapy can be used if local H. pylori resistance to clarithromycin is known to be less than 15%.

For second-line H. pylori eradication, bismuth-based quadruple therapies and 14-day levofloxacin-based triple therapy can be used, provided that antibiotics other than those used in the first-line regimen are used. Third-line H. pylori eradication regimens have not been addressed in Iranian studies. However, most guidelines recommend treatment according to the results of culture and susceptibility testing.

Although we limited our investigation to H. pylori eradication regimens in Iran, the results are transferrable to any region as long as the patterns of antibiotic resistance are the same.

Consensus on the clinical management, screening-to-treat, and surveillance of Helicobacter pylori infection to improve gastric cancer control on a nationwide scale

BACKGROUND

Previous international consensus statements provided general policies for the management of Helicobacter pylori infection. However, there are geographic differences in the prevalence and antimicrobial resistance of H. pylori, and in the availability of medications and endoscopy. Thus, nationwide or regional consensus statements are needed to improve control of H. pylori infection and gastric cancer.

MATERIALS AND METHODS

This consensus statement for management of H. pylori in Taiwan has three major sections: (1) optimal diagnosis and indications; (2) current treatment strategies; and (3) screening-to-treat and surveillance for control of gastric cancer. The literature review emphasized recent data for development of draft statements and determination of levels of evidence. Twenty-five Taiwan experts conducted a consensus conference, by a modified Delphi process, to modify the draft statements. Consensus, defined as an agreement of least 80% of the experts, and recommendation grade were determined by anonymous voting.

RESULTS

There were 24 consensus statements. Section 1 has seven statements on recommendations for the diagnosis and indications for treatment of H. pylori infection. Section 2 has 10 statements that provide an updated treatment algorithm for first-line, second-line, and third-line regimens. Section 3 has seven statements regarding H. pylori eradication for reducing the risk of gastric cancer, with a cost-benefit analysis. After H. pylori eradication, the consensus highlights the use of endoscopic surveillance and/or chemoprevention to further reduce the burden of gastric cancer.

CONCLUSIONS

This consensus statement has updated recommendations for improving the clinical management of H. pylori infection in areas such as Taiwan, which have high prevalence of H. pylori infection and gastric cancer.

Effects of anti-Helicobacter pylori concomitant therapy and probiotic supplementation on the throat and gut microbiota in humans

The microbiota within humans maintains homeostasis and plays important roles in human health. However, some situations such as the use of antibiotics may disrupt the microbiota balance and result in a series of adverse effects. This study aimed to investigate the effects of a commonly used anti-Helicobacter pylori concomitant therapy on the composition of the gut and throat microbiota and any antibiotic resistance that may develop. In addition to the standard regimen, two different supplementary probiotic regimens that both used Saccharomyces boulardii were included. Microbiological culture-based techniques were used to analyse the microbiota composition and antibiotic resistance. Our results showed marked quantitative and qualitative alterations in both the gut and throat microbiota after treatment with not only the standard concomitant therapy but also with either supplementary probiotic regimen. Nevertheless, most of the changes in the gut microbiota (except for yeast and Bacteroides spp. counts) reverted by Day 71, whereas the alterations in the throat microbiota appeared to persist. Patients treated with the eradication therapy in the absence of probiotic supplementation experienced the most pronounced disturbances in the throat microbiota, whereas changes in the throat microbiota appeared to stabilize in the groups that received probiotic supplementation. We also detected higher antibiotic resistance rates for Enterobacteriaceae, Enterococcus spp. and Bacteroides spp. after treatment with the eradication therapy. Co-administration of probiotics is likely to be more effective than post-antibiotic supplementation, and although some beneficial effects were observed, the probiotic combination did not exert significant effects on the unbalanced commensal gut and throat microbiota composition.

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%.

ACG Clinical Guideline: Treatment of Helicobacter pylori Infection

Helicobacter pylori (H. pylori) infection is a common worldwide infection that is an important cause of peptic ulcer disease and gastric cancer. H. pylori may also have a role in uninvestigated and functional dyspepsia, ulcer risk in patients taking low-dose aspirin or starting therapy with a non-steroidal anti-inflammatory medication, unexplained iron deficiency anemia, and idiopathic thrombocytopenic purpura. While choosing a treatment regimen for H. pylori, patients should be asked about previous antibiotic exposure and this information should be incorporated into the decision-making process. For first-line treatment, clarithromycin triple therapy should be confined to patients with no previous history of macrolide exposure who reside in areas where clarithromycin resistance amongst H. pylori isolates is known to be low. Most patients will be better served by first-line treatment with bismuth quadruple therapy or concomitant therapy consisting of a PPI, clarithromycin, amoxicillin, and metronidazole. When first-line therapy fails, a salvage regimen should avoid antibiotics that were previously used. If a patient received a first-line treatment containing clarithromycin, bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options. If a patient received first-line bismuth quadruple therapy, clarithromycin or levofloxacin-containing salvage regimens are the preferred treatment options. Details regarding the drugs, doses and durations of the recommended and suggested first-line and salvage regimens can be found in the guideline.

Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report

Important progress has been made in the management of Helicobacter pylori infection and in this fifth edition of the Maastricht Consensus Report, key aspects related to the clinical role of H. pylori were re-evaluated in 2015. In the Maastricht V/Florence Consensus Conference, 43 experts from 24 countries examined new data related to H. pylori in five subdivided workshops: (1) Indications/Associations, (2) Diagnosis, (3) Treatment, (4) Prevention/Public Health, (5) H. pylori and the Gastric Microbiota. The results of the individual workshops were presented to a final consensus voting that included all participants. Recommendations are provided on the basis of the best available evidence and relevance to the management of H. pylori infection in the various clinical scenarios.

Optimal First-Line Treatment for Helicobacter pylori Infection: Recent Strategies

A new treatment strategy is needed, as the efficacy of triple therapy containing clarithromycin—the current standard treatment for Helicobacter pylori infection—is declining. Increasing antibiotic resistance of H. pylori is the most significant factor contributing to eradication failure. Thus, selecting the most appropriate regimen depending on resistance is optimal, but identifying resistance to specific antibiotics is clinically challenging. In a region suspected to have high clarithromycin resistance, bismuth quadruple therapy and so-called nonbismuth quadruple therapies (sequential, concomitant, and sequential-concomitant hybrid) are some first-line regimen options. However, more research is needed regarding appropriate second-line treatments after first-line treatment failure. Tailored therapy, which is based on antibiotic sensitivity testing, would be optimal but has several limitations for clinical use, and an alternative technique is required. A novel potassium-competitive acid blocker-based eradication regimen could be a valuable eradication option in the near future.

Treatment of Helicobacter pylori infection: Where are we now?

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

Current status of Helicobacter pylori infection and evolution of treatment strategy in China

Infection with Helicobacter pylori (H. pylori) has become a common digestive disease and the prevalence of H. pylori infection remains high in the Chinese population. Recently, the Kyoto global consensus report on H. pylori gastritis and the Toronto consensus for the treatment of H. pylori infection in adults were issued. Therefore, it is essential to discuss the prevention and control of H. pylori infection in China. Due to severe resistance to antibiotics, toxic and host factors, the eradication rate in China has currently became lower than before. Therefore, whether to intervene H. pylori infection in the asymptomatic population and enlarge the indication for eradication and the cost-effect for this new strategy should be discussed. In addition, the implementation of the "test and treat" policy or not in China is debatable. Developing optimal treatment strategy has become a major challenge that clinicians face. This review focuses on the current H. pylori infection situation and the evolution of treatment strategies in China.

Pharmacological regimens for eradication of Helicobacter pylori: an overview of systematic reviews and network meta-analysis

BACKGROUND

Approximately half of the world's population is infected with Helicobacter pylori (H.pylori), a bacterium shown to be linked with a series of gastrointestinal diseases. A growing number of systematic reviews (SRs) have been published comparing the effectiveness of different treatments for H.pylori infection but have not reached a consistent conclusion. The objective of this study is to provide an overview of SRs of pharmacological therapies for the eradication of H.pylori.

METHODS

Major electronic databases were searched to identify relevant SRs published between 2002 and February 2016. Studies were considered eligible if they included RCTs comparing different pharmacological regimens for treating patients diagnosed as H.pylori infected and pooled the eradication rates in a meta-analysis. A modified version of the 'A Measurement Tool to Assess Systematic Reviews' (AMSTAR) was used to assess the methodological quality. A Bayesian random effects network meta-analysis (NMA) was conducted to compare the different proton pump inhibitors (PPI) within triple therapy.

RESULTS

30 SRs with pairwise meta-analysis were included. In triple therapy, the NMA ranked the esomeprazole to be the most effective PPI, followed by rabeprazole, while no difference was observed among the three old generations of PPI for the eradication of H.pylori. When comparing triple and bismuth-based therapy, the relative effectiveness appeared to be dependent on the choice of antibiotics within the triple therapy; moxifloxacin or levofloxacin-based triple therapy were both associated with greater effectiveness than bismuth-based therapy as a second-line treatment, while bismuth-based therapy achieved similar or greater eradication rate compared to clarithromycin-based therapy. Inconsistent findings were reported regarding the use of levofloxacin/moxifloxacin in the first-line treatment; this could be due to the varied resistant rate to different antibiotics across regions and populations. Critical appraisal showed a low-moderate level of overall methodological quality of included studies.

CONCLUSIONS

Our analysis suggests that the new generation of PPIs and use of moxifloxacin or levofloxacin within triple therapy as second-line treatment were associated with greater effectiveness. Given the varied antibiotic resistant rate across regions, the appropriateness of pooling results together in meta-analysis should be carefully considered and the recommendation of the choice of antibiotics should be localized.

Eradication of Helicobacter pylori Infection

Helicobacter pylori infects about 50 % of the world's population, causing at a minimum chronic gastritis. A subset of infected patients will ultimately develop gastric or duodenal ulcer disease, gastric adenocarcinoma, or MALT (mucosa-associated lymphoid tissue) lymphoma. Eradication of H. pylori requires complex regimens that include acid suppression and multiple antibiotics. The efficacy of treatment using what were once considered standard regimens have declined in recent years, mainly due to widespread development of antibiotic resistance. Addition of bismuth to standard triple therapy regimens, use of alternate antibiotics, or development of alternative regimens using known therapies in novel combinations have improved treatment efficacy in specific populations, but overall success of eradication remains less than ideal. Novel regimens under investigation either in vivo or in vitro, involving increased acid suppression ideally with fewer antibiotics or development of non-antibiotic treatment targets, show promise for future therapy.

Randomized clinical trial comparing ten day concomitant and sequential therapies for Helicobacter pylori eradication in a high clarithromycin resistance area

BACKGROUND

Currently only a few studies compare sequential and concomitant non-bismuth Helicobacter pylori therapies referring to high antibiotic resistance populations.

MATERIALS AND METHODS

This multicenter prospective randomized clinical trial included 353 H. pylori positive, treatment naïve, patients. All patients had positive CLO-test and/or histology and culture. They received sequential (esomeprazole 40mg, amoxicillin 1g/bid for 5days, followed by 5days of esomeprazole 40mg, clarithromycin 500mg and metronidazole 500mg bid), or concomitant treatment (all drugs taken concomitantly bid for 10days). Eradication was confirmed by (13)C-urea breath test or histology 4-6weeks after treatment. Adverse events and adherence were evaluated.

RESULTS

Allocated to concomitant were 175 (72F/103M, mean 52.3years, 38.3% smokers, 25.7% ulcer disease) and 178 (87F/91M, mean 52years, 31% smokers, 19.1% ulcer disease) patients to sequential treatment. There were 303/353 (85.8%) positive cultures, with the following resistances: 34% metronidazole, 27.7% clarithromycin, and 7.9% dual. Eradication rates were, respectively, 89.1% (156/175) vs. 78.7% (140/178) by intention to treat (p=0.01, 95% CI=2.7-18) and 93.4%(156/167) vs. 82.8% (140/169) per protocol (p=0.004, 95% CI=3.6-17.6). Overall, adherence was (98.9%, 95% CI=97-100). Eradication rates according to resistance were the following: dual susceptible strains 67/69 (97.1%), 62/67 (92%) (p=0.4), metronidazole single resistant 38/39 (97.4%), 31/39 (79.5%) (p=0.03, 95% CI=3.5-33), clarithromycin single resistant 25/28 (89.3%), 26/31 (83.9%) (p=0.8), and dual resistant 9/12 (75%), 4/11 (36.4%) (p=0.1) for concomitant and sequential regimens, respectively. Side effects were comparable among regimens, except from diarrhea being more frequent among patients treated with concomitant treatment.

CONCLUSIONS

Concomitant treatment eradication rate overcomes 90% per protocol and has a significant advantage over sequential therapy. This is probably due to its better efficacy on metronidazole resistant strains. Both regimens were well tolerated and safe.

Sequential versus standard triple first-line therapy for Helicobacter pylori eradication

BACKGROUND

Non-bismuth quadruple sequential therapy (SEQ) comprising a first induction phase with a dual regimen of amoxicillin and a proton pump inhibitor (PPI) for five days followed by a triple regimen phase with a PPI, clarithromycin and metronidazole for another five days, has been suggested as a new first-line treatment option to replace the standard triple therapy (STT) comprising a proton pump inhibitor (PPI), clarithromycin and amoxicillin, in which eradication proportions have declined to disappointing levels.

OBJECTIVES

To conduct a meta-analysis of randomised controlled trials (RCTs) comparing the efficacy of a SEQ regimen with STT for the eradication of H. pylori infection, and to compare the incidence of adverse effects associated with both STT and SEQ H. pylori eradication therapies.

SEARCH METHODS

We conducted bibliographical searches in electronic databases, and handsearched abstracts from Congresses up to April 2015.

SELECTION CRITERIA

We sought randomised controlled trials (RCTs) comparing 10-day SEQ and STT (of at least seven days) for the eradication of H. pylori. Participants were adults and children diagnosed as positive for H. pylori infection and naïve to H. pylori treatment.

DATA COLLECTION AND ANALYSIS

We used a pre-piloted, tabular summary to collect demographic and medical information of included study participants as well as therapeutic data and information related to the diagnosis and confirmatory tests.We evaluated the difference in intention-to-treat eradication between SEQ and STT regimens across studies, and assessed sources of the heterogeneity of this risk difference (RD) using subgroup analyses.We evaluated the quality of the evidence following Cochrane standards, and summarised it using GRADE methodology.

MAIN RESULTS

We included 44 RCTs with a total of 12,284 participants (6042 in SEQ and 6242 in STT). The overall analysis showed that SEQ was significantly more effective than STT (82% vs 75% in the intention-to-treat analysis; RD 0.09, 95% confidence interval (CI) 0.06 to 0.11; P < 0.001, moderate-quality evidence). Results were highly heterogeneous (I² = 75%), and 20 studies did not demonstrate differences between therapies.Reporting by geographic region (RD 0.09, 95% CI 0.06 to 0.12; studies = 44; I² = 75%, based on low-quality evidence) showed that differences between SEQ and STT were greater in Europe (RD 0.16, 95% CI 0.14 to 0.19) when compared to Asia, Africa or South America. European studies also showed a tendency towards better efficacy with SEQ; however, this tendency was reversed in 33% of the Asian studies. Africa reported the closest risk difference (RD 0.14 , 95% 0.07 to 0.22) to Europe among studied regions, but confidence intervals were wider and therefore the quality of the evidence showing SEQ to be superior to STT was reduced for this region.Based on high-quality evidence, subgroup analyses showed that SEQ and STT therapies were equivalent when STT lasted for 14 days. Although, overall, the mean eradication proportion with SEQ was over 80%, we noted a tendency towards a lower average effect with this regimen in the more recent studies (2008 and after); weighted linear regression showed that the efficacies of both regimens evolved differently over the years, having a higher reduction in the efficacy of SEQ (-1.72% yearly) than in STT (-0.9% yearly). In these more recent studies (2008 and after) we were also unable to detect the superiority of SEQ over STT when STT was given for 10 days.Based on very low-quality evidence, subgroup analyses on antibiotic resistance showed that the widest difference in efficacy between SEQ and STT was in the subgroup analysis based on clarithromycin-resistant participants, in which SEQ reached a 75% average efficacy versus 43% with STT.Reporting on adverse events (AEs) (RD 0.00, 95% CI -0.02 to 0.02; participants = 8103; studies = 27; I² = 26%, based on high-quality evidence) showed no significant differences between SEQ and STT (20.4% vs 19.5%, respectively) and results were homogeneous.The quality of the studies was limited due to a lack of systematic reporting of the factors affecting risk of bias. Although randomisation was reported, its methodology (e.g. algorithms, number of blocks) was not specified in several studies. Additionally, the other 'Risk of bias' domains (such as allocation concealment of the sequence randomisation, or blinding during either performance or outcome assessment) were also unreported.However, subgroup analyses as well as sensitivity analyses or funnel plots indicated that treatment outcomes were not influenced by the quality of the included studies. On the other hand, we rated 'length of STT' and AEs for the main outcome as high-quality according to GRADE classification; but we downgraded 'publication date' quality to moderate, and 'geographic region' and 'antibiotic resistance' to low- and very low-quality, respectively.

AUTHORS' CONCLUSIONS

Our meta-analysis indicates that prior to 2008 SEQ was more effective than STT, especially when STT was given for only seven days. Nevertheless, the apparent advantage of sequential treatment has decreased over time, and more recent studies do not show SEQ to have a higher efficacy versus STT when STT is given for 10 days.Based on the results of this meta-analysis, although SEQ offers an advantage when compared with STT, it cannot be presented as a valid alternative, given that neither SEQ nor STT regimens achieved optimal efficacy ( ≥ 90% eradication rate).

IV Spanish Consensus Conference on Helicobacter pylori infection treatment

Helicobacter pylori approximately infect 50% of Spanish population and causes chronic gastritis, peptic ulcer and gastric cancer. Until now, three consensus meetings on H.pylori infection had been performed in Spain (the last in 2012). The changes in the treatment schemes, and the increasing available evidence, have justified organizing the IVSpanish Consensus Conference (March 2016), focused on the treatment of this infection. Nineteen experts participated, who performed a systematic review of the scientific evidence and developed a series of recommendation that were subjected to an anonymous Delphi process of iterative voting. Scientific evidence and the strength of the recommendation were classified using GRADE guidelines. As starting point, this consensus increased the minimum acceptable efficacy of recommended treatments that should reach, or preferably surpass, the 90% cure rate when prescribed empirically. Therefore, only quadruple therapies (with or without bismuth), and generally lasting 14 days, are recommended both for first and second line treatments. Non-bismuth quadruple concomitant regimen, including a proton pump inhibitor, clarithromycin, amoxicillin and metronidazole, is recommended as first line. In the present consensus, other first line alternatives and rescue treatments are also reviewed and recommended.

Randomized clinical trial comparing 10-day sequential, 7-day concomitant and 7-day standard triple therapies for Helicobacter pylori eradication

OBJECTIVES

To compare triple therapy with sequential and concomitant therapies directly in a head-to-head comparison in Helicobacter pylori-infected patients.

DESIGN

Patients were allocated randomly as follows: a triple therapy with esomeprazole (20 mg), amoxicillin (1000 mg) and clarithromycin (500 mg) twice daily for 7 days; a sequential therapy with 5 days of esomeprazole (20 mg) and amoxicillin (1000 mg) twice daily, followed by 5 days of esomeprazole (20 mg), clarithromycin (500 mg) and metronidazole (400 mg) twice daily; or a concomitant therapy consisting of esomeprazole (20 mg), amoxicillin (1000 mg), clarithromycin (500 mg) and metronidazole (400 mg) twice daily for 7 days.

RESULTS

A total of 356 consecutive patients were included. The eradication rates for the triple, sequential and concomitant therapies were 83.6% [95% confidence interval (CI) 76.9-90.4%], 94.2% (95% CI 90.0-98.4%) and 91.7% (95% CI 86.7-96.6%), respectively, in the intention-to-treat population. The differences were significant only between triple and sequential therapies (P=0.01). The primary resistance rates to amoxicillin, clarithromycin and metronidazole were 0.6, 10.5 and 25.9%, respectively. Concomitant therapy was significantly better than triple therapy in cases with clarithromycin resistance (P=0.01).

CONCLUSION

Ten-day sequential therapy was significantly better than 7-day triple therapy in a clinical setting with low rates of clarithromycin and dual resistance. Concomitant therapy was significantly better than standard triple therapy in the subgroup of patients with clarithromycin-resistant strains.

Sequential (as Opposed to Simultaneous) Antibiotic Therapy Improves Helicobacter pylori Eradication in the Pediatric Population: A Meta-Analysis

Helicobacter pylori is a common infection associated with many gastrointestinal diseases. Triple or quadruple therapy is the current recommendation for H pylori eradication in children but is associated with success rates as low as 50%. Recent studies have demonstrated that a 10-day sequential therapy regimen, rather than simultaneous antibiotic administration, achieved eradication rates of nearly 95%. This meta-analysis found that sequential therapy increased eradication rates by 14.2% (relative risk [RR] = 1.142; 95% confidence interval [CI] = 1.082-1.207; P < .001). Ten-day sequential therapy significantly improved H pylori eradication rates compared to the 7-day standard therapy (RR = 1.182; 95% CI = 1.102-1.269; p < .001) and 10-day standard therapy (RR = 1.179; 95% CI = 1.074-1.295; P = .001), but had lower eradication rates compared to 14-day standard therapy (RR = 0.926; 95% CI = 0.811-1.059; P = .261). The use of sequential therapy is associated with increased H pylori eradication rates in children compared to standard therapy of equal or shorter duration.