Efficacy and safety of rifabutin-containing 'rescue therapy' for resistant Helicobacter pylori infection

The effectiveness of rifabutin triple therapy for patients with difficult-to-eradicate Helicobacter pylori in clinical practice

BACKGROUND

Failure of first line and subsequent Helicobacter pylori eradication therapy is a significant problem and alternative treatments are few.

AIMS

To evaluate the efficacy of a rifabutin-based triple therapy in clinical practice and determine the optimal strategy for its use.

METHODS

Patients referred after first or subsequent treatment failure were prescribed rifabutin triple therapy consisting of standard dose proton pump inhibitor, amoxicillin 1 g and rifabutin 150 mg each b.d. for 10 days.

RESULTS

In 67 patients, the main indications for treatment were dyspepsia (55%), peptic ulcer disease (24%) and increased gastric cancer risk (18%). The median number of previous treatments was 2 (range: 1-9). Eradication of Helicobacter pylori was achieved in 76% (48/63) per protocol and 72% (48/67) on an intention-to-treat basis. When used as second line therapy, 95% (18/19) achieved eradication compared with 68% (30/44) when two or more previous treatments had been used (P = 0.03). Outcome was independent of age, ethnicity, gender or indication for treatment. Adverse events were reported in 10%.

CONCLUSION

Rifabutin triple therapy is a well tolerated and effective second line therapy in the treatment of persistent Helicobacter pylori; however, its efficacy decreases with increasing number of failed previous therapies.

A meta-analysis of the success rate of Helicobacter pylori therapy in Canada

BACKGROUND AND AIM

Helicobacter pylori treatment success rates have varied. A systematic review of the success rate of anti- H pylori therapy in Canada was performed.

METHODS

All clinical trials containing Canadian data on the success rate of H pylori treatment were identified using MEDLINE searches, through review of references of retrieved studies and by contacting key investigators. Both randomized and open-label trials were included. Treatment effect size was calculated using a variation of Cochran's Q method.

RESULTS

Seventeen papers met the inclusion criteria. Both triple therapies consisting of a proton pump inhibitor (PPI), clarithromycin and either amoxicillin or metronidazole performed well, achieving a success rate of 84% and 82%, respectively. The cure rate of PPI-amoxicillin + metronidazole was 76%. Quadruple therapy consisting of a PPI, bismuth, metronidazole and tetracycline, given for seven to 10 days, achieved a success rate of 87%.

CONCLUSION

Both PPI-based triple therapy and quadruple therapy perform well in Canada for the treatment of H pylori infection.

American College of Gastroenterology guideline on the management of Helicobacter pylori infection

Helicobacter pylori (H. pylori) remains a prevalent, worldwide, chronic infection. Though the prevalence of this infection appears to be decreasing in many parts of the world, H. pylori remains an important factor linked to the development of peptic ulcer disease, gastric malignanc and dyspeptic symptoms. Whether to test for H. pylori in patients with functional dyspepsia, gastroesophageal reflux disease (GERD), patients taking nonsteroidal antiinflammatory drugs, with iron deficiency anemia, or who are at greater risk of developing gastric cancer remains controversial. H. pylori can be diagnosed by endoscopic or nonendoscopic methods. A variety of factors including the need for endoscopy, pretest probability of infection, local availability, and an understanding of the performance characteristics and cost of the individual tests influences choice of evaluation in a given patient. Testing to prove eradication should be performed in patients who receive treatment of H. pylori for peptic ulcer disease, individuals with persistent dyspeptic symptoms despite the test-and-treat strategy, those with H. pylori-associated MALT lymphoma, and individuals who have undergone resection of early gastric cancer. Recent studies suggest that eradication rates achieved by first-line treatment with a proton pump inhibitor (PPI), clarithromycin, and amoxicillin have decreased to 70-85%, in part due to increasing clarithromycin resistance. Eradication rates may also be lower with 7 versus 14-day regimens. Bismuth-containing quadruple regimens for 7-14 days are another first-line treatment option. Sequential therapy for 10 days has shown promise in Europe but requires validation in North America. The most commonly used salvage regimen in patients with persistent H. pylori is bismuth quadruple therapy. Recent data suggest that a PPI, levofloxacin, and amoxicillin for 10 days is more effective and better tolerated than bismuth quadruple therapy for persistent H. pylori infection, though this needs to be validated in the United States.

Efficacy of rifabutin-based triple therapy as second-line treatment to eradicate helicobacter pylori infection

Background

Rifabutin has been found to be effective in multi-resistant patients after various treatment cycles for Helicobacter pylori (HP) infection, but it has not been analysed as a second-line treatment. Therefore, we seek to compare the effectiveness of a treatment regimen including rifabutin versus conventional quadruple therapy (QT).

Methods

Open clinical trial, randomised and multi-centre, of two treatment protocols: A) Conventional regime -QT- (omeprazole 20 mg bid, bismuth citrate 120 mg qid, tetracycline 500 mg qid and metronidazole 500 mg tid); B) Experimental one -OAR- (omeprazole 20 mg bid, amoxicillin 1 gr bid, and rifabutin 150 mg bid), both taken orally for 7 days, in patients with HP infection for whom first-line treatment had failed. Eradication was determined by Urea Breath Test (UBT). Safety was determined by the adverse events.

Results

99 patients were randomised, QT, n = 54; OAR, n = 45. The two groups were homogeneous. In 8 cases, treatment was suspended (6 in QT and 2 in OAR). The eradication achieved, analysed by ITT, was for QT, 38 cases (70.4%), and for OAR, 20 cases (44.4%); p = 0.009, OR = 1.58. Of the cases analysed PP, QT were 77.1%; OAR, 46.5%; p = 0.002. Adverse effects were described in 64% of the QT patients and in 44% of the OAR patients (p = 0.04).

Conclusion

A 7-day rifabutin-based triple therapy associated to amoxicillin and omeprazole at standard dose was not found to be effective as a second-line rescue therapy. The problem with quadruple therapy lies in the adverse side effects it provokes. We believe the search should continue for alternatives that are more comfortably administered and that are at least as effective, but with fewer adverse side effects.

Trial Registration

Current Controlled Trials ISRCTN81058036

Dual therapy with high doses of rabeprazole and amoxicillin versus triple therapy with rabeprazole, amoxicillin, and metronidazole as a rescue regimen for Helicobacter pylori infection after the standard triple therapy

BACKGROUNDS AND AIMS

Development of safe and effective rescue regimens for eradication failure of Helicobacter pylori infection by standard regimens is an urgent task. We designed the prospective study to compare the efficacy of two rescue regimens after eradication failure by the standard triple therapy.

METHODS

One hundred and thirty-two patients in whom eradication of H. pylori infection failed initial triple therapy with lansoprazole 30 mg b.i.d, amoxicillin 750 mg b.i.d. and clarithromycin 400 mg b.i.d. for 1 week were randomized to either the 1-week triple therapy with rabeprazole 10 mg b.i.d., amoxicillin 750 mg b.i.d., and metronidazole 250 mg b.i.d. (RAM) or the 2-week dual therapy with rabeprazole 10 mg q.i.d. and amoxicillin 500 mg q.i.d. (RA). Eradication of H. pylori was judged by (13)C-urea breath test 1 month later.

RESULTS

The intention-to-treat and per-protocol-based eradication rates were 92.4% (95% CI: 83.2-97.5) and 95.3% (95% CI: 86.9-99.0) for the RAM therapy and 90.9% (95% CI: 81.2-96.6) and 93.8% (95% CI: 84.8-98.3), respectively, for the RA therapy (P > 0.2 for both). No clinically recognizable adverse events were observed with either regimen.

CONCLUSION

RA as well as RAM therapy are safe and effective rescue regimens for H. pylori infection after eradication failure by the standard triple therapy.

Treatment of Helicobacter pylori

Triple therapy, consisting of two antibiotics, clarithomycin and amoxicillin or metronidazole in combination with a proton pump inhibitor (PPI) has become the first-line option for infection with Helicobacter pylori and has been recommended at several consensus conferences. In clinical practice, approximately 20% of patients will fail to obtain H. pylori eradication with the recommended treatment regimens. Major causes of treatment failure are insufficient patient compliance and antibiotic resistance. Because of antibiotic resistance, bismuth-based quadruple therapy has also become a first-line regimen in areas with exceedingly high rates of clarithromycin and metronidazole resistance, and is the preferred second-line option otherwise. Triple therapies based on levofloxacin and/or rifabutin mainly with combination of amoxicillin are options if multiple eradication failure occurs. However, following therapy failure beyond a second treatment attempt requires antibiotic resistance testing. New drugs and adjuvant agents have been reported but their efficacy needs further evaluation.

Effective regimens for the treatment of Helicobacter pylori infection

Successful Helicobacter pylori eradication therapy remains a challenge in medical practice. Currently, a proton pump inhibitor-based triple therapy containing clarithromycin, amoxicillin or nitroimidazole for 7 days is the recommended first-line treatment approach with an expected eradication success rate of approximately 80%. As a second-line treatment option in the case of failure, a ranitidine bismuth citrate-based quadruple therapy is currently recommended curing another 80% of patients, leaving a subset of patients with persistent H. pylori infection. For these patients, promising rescue options have been evaluated including regimens that contain rifabutin, quinolones, furazolidone or high-dose amoxicillin. The role of susceptibility testing is still under discussion. It is not generally recommended prior to first-line treatment but guidelines propose a role for culture and antibiotic sensitivity testing after failure of the second attempt. Meanwhile, data on the geographic distribution of resistance pattern are available and may guide therapeutic decisions with regard to the combination of antibiotics chosen for the individual patients aiming at 100% cure rate in each individual patient.

Peptic ulcer disease

PURPOSE OF REVIEW

This review attempts to contextualize some of the clinically important publications of the last 2 years as they relate to the broad topic of dyspepsia and peptic ulcer disease, both Helicobacter pylori and nonsteroidal anti-inflammatory drug-related.

RECENT FINDINGS

This review includes findings which provide insight with regard to the triaging of dyspeptic subjects, information on new proton pump inhibitor drugs and H. pylori eradication 'rescue regimens'. The 'COX-2 debacle' is discussed and new data relating to the efficacy of co-therapy strategies for the prevention of nonsteroidal anti-inflammatory drug gastropathy are presented, while the use of antiplatelet agents as 'safe' substitutes for aspirin cardioprophylaxis is questioned. The important issue of proton pump inhibitor safety and nonsteroidal anti-inflammatory drug enteropathy are addressed.

SUMMARY

The review provides a summary and interpretation of literature pertaining to the above issues, and should provide a point of departure for clinical decision-making relevant to these issues.

Treatment of Helicobacter pylori infection

In clinical practice the recommended treatment regimens achieve only an 80%Helicobacter pylori eradication rate and this rate is lower in patients who have failed first-line treatment. The increasing indications for H. pylori treatment (idiopathic thrombocytopenia and iron deficiency anemia) and an increasing trend of antibiotic resistance (especially in southern Europe) emphasize the need for more effective H. pylori eradication. Smoking and a short duration of treatment, especially in patients with functional dyspepsia, are predictors of eradication failure. In first line, the best option remains the clarithromycin-based regimens but an extended treatment duration is now indicated. Following first-line treatment failure, 14-day proton pump inhibitor triple therapy employing alternative antibiotics or quadruple therapy could be used. Levofloxacin-based 10-day triple therapy seems to be an encouraging strategy following one or more eradication failures.

Third-line rescue therapy for Helicobacter pylori infection

H pylori gastric infection is one of the most prevalent infectious diseases worldwide. The discovery that most upper gastrointestinal diseases are related to H pylori infection and therefore can be treated with antibiotics is an important medical advance. Currently, a first-line triple therapy based on proton pump inhibitor (PPI) or ranitidine bismuth citrate (RBC) plus two antibiotics (clarithromycin and amo-xicillin or nitroimidazole) is recommended by all consensus conferences and guidelines. Even with the correct use of this drug combination, infection can not be eradicated in up to 23% of patients. Therefore, several second line therapies have been recommended. A 7 d quadruple therapy based on PPI, bismuth, tetracycline and metronidazole is the more frequently accepted. However, with second-line therapy, bacterial eradication may fail in up to 40% of cases. When H pylori eradication is strictly indicated the choice of further treatment is controversial. Currently, a standard third-line therapy is lacking and various protocols have been proposed. Even after two consecutive failures, the most recent literature data have demonstrated that H pylori eradication can be achieved in almost all patients, even when antibiotic susceptibility is not tested. Different possibilities of empirical treatment exist and the available third-line strategies are herein reviewed.