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Huang Y, Chen J, Ding Z, Chen X, Liang X, Zeng X, Xu F, Han Y, Lu H. Minocycline vs. tetracycline in bismuth-containing quadruple therapy for Helicobacter pylori rescue treatment: a multicentre, randomized controlled trial. J Gastroenterol 2023; 58:633-641. [PMID: 37042991 DOI: 10.1007/s00535-023-01991-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/31/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND To compare the efficacy and tolerability of minocycline vs. tetracycline in bismuth-containing quadruple therapy for Helicobacter pylori (H. pylori) rescue treatment. METHODS This study was a multi-center, randomized-controlled, non-inferiority trial. Refractory H. pylori-infected subjects with multiple treatment-failure were randomly (1:1) allocated to receive 14-day therapy with esomeprazole 20 mg b.i.d, bismuth 220 mg b.i.d, plus metronidazole 400 mg q.i.d and minocycline 100 mg b.i.d (minocycline group) or tetracycline 500 mg q.i.d (tetracycline group). Primary outcome was H. pylori eradication rate evaluated by 13C-urea breath test at least 6 weeks after the end of treatment. Antibiotic resistance was determined using E test method. RESULTS Three hundred and sixty-eight subjects were randomized. The eradication rates in minocycline group and tetracycline group were 88.0% (162/184, 95% CI 83.3-92.8%) and 88.6% (163/184, 95% CI 83.9-93.2%) in intention-to-treat analysis, 98.0% (149/152, 95% CI 95.8-100%) and 97.4% (150/154, 95% CI 94.9-99.9%) in per-protocol analysis, 93.1% (162/174, 95% CI 89.3-96.9%) and 93.1% (163/175, 95% CI 89.4-96.9%) in modified intention-to-treat analysis. Minocycline, tetracycline and metronidazole resistance rates were 0.7%, 1.4% and 89.6%, respectively. Non-inferiority of minocycline was confirmed (P < 0.025). Metronidazole resistance did not affect the efficacy of either therapy. The two therapies exhibited comparable frequencies of adverse events (55.4% vs. 53.3%); almost half of them were mild. Dizziness was the most common adverse events in the minocycline group. CONCLUSIONS Minocycline can be an alternative for tetracycline in bismuth-containing quadruple therapy for H. pylori empirical rescue treatment, irrespective of metronidazole resistance. However, relatively high incidence of adverse events in both regimens should be emphasized.
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Affiliation(s)
- Yu Huang
- NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jinnan Chen
- NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhaohui Ding
- NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xi Chen
- NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiao Liang
- NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xin Zeng
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fei Xu
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuehua Han
- Department of Gastroenterology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Hong Lu
- NHC Key Laboratory of Digestive Diseases, Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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de Moraes Andrade PV, Monteiro YM, Chehter EZ. Third-line and rescue therapy for refractory Helicobacter pylori infection: A systematic review. World J Gastroenterol 2023; 29:390-409. [PMID: 36687120 PMCID: PMC9846933 DOI: 10.3748/wjg.v29.i2.390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/12/2022] [Accepted: 12/01/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Due to increasing resistance rates of Helicobacter pylori (H. pylori) to different antibiotics, failures in eradication therapies are becoming more frequent. Even though eradication criteria and treatment algorithms for first-line and second-line therapy against H. pylori infection are well-established, there is no clear recommendation for third-line and rescue therapy in refractory H. pylori infection.
AIM To perform a systematic review evaluating the efficacy and safety of rescue therapies against refractory H. pylori infection.
METHODS A systematic search of available rescue treatments for refractory H. pylori infection was conducted on the National Library of Medicine’s PubMed search platform based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized or non-randomized clinical trials and observational studies evaluating the effectiveness of H. pylori infection rescue therapies were included.
RESULTS Twenty-eight studies were included in the analysis of mean eradication rates as rescue therapy, and 21 of these were selected for analysis of mean eradication rate as third-line treatment. For rifabutin-, sitafloxacin-, levofloxacin-, or metronidazole-based triple-therapy as third-line treatment, mean eradication rates of 81.6% and 84.4%, 79.4% and 81.5%, 55.7% and 60.6%, and 62.0% and 63.0% were found in intention-to-treat (ITT) and per-protocol (PP) analysis, respectively. For third-line quadruple therapy, mean eradication rates of 69.2% and 72.1% were found for bismuth quadruple therapy (BQT), 88.9% and 90.9% for bismuth quadruple therapy, three-in-one, Pylera® (BQT-Pylera), and 61.3% and 64.2% for non-BQT) in ITT and PP analysis, respectively. For rifabutin-, sitafloxacin-, levofloxacin-, or metronidazole-based triple therapy as rescue therapy, mean eradication rates of 75.4% and 78.8%, 79.4 and 81.5%, 55.7% and 60.6%, and 62.0% and 63.0% were found in ITT and PP analysis, respectively. For quadruple therapy as rescue treatment, mean eradication rates of 76.7% and 79.2% for BQT, 84.9% and 87.8% for BQT-Pylera, and 61.3% and 64.2% for non-BQT were found in ITT and PP analysis, respectively. For susceptibility-guided therapy, mean eradication rates as third-line and rescue treatment were 75.0% in ITT and 79.2% in PP analysis.
CONCLUSION We recommend sitafloxacin-based triple therapy containing vonoprazan in regions with low macrolide resistance profile. In regions with known resistance to macrolides or unavailability of bismuth, rifabutin-based triple therapy is recommended.
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Affiliation(s)
| | - Yan Mosca Monteiro
- Department of Gastroenterology, Faculdade de Medicina do ABC, Santo André 09060-650, SP, Brazil
| | - Ethel Zimberg Chehter
- Department of Gastroenterology, Faculdade de Medicina do ABC, Santo André 09060-650, SP, Brazil
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Alavinejad P, Nayebi M, Parsi A, Abdelsameea E, Ahmed MH, Hormati A, Viet Hang D, Pezeshgi Modarres M, Cheraghian B, Baghaee S, Farbod Ara T, Trung Tran Q, Shanker Behl N, Hashemi SJ, Alboraie M, Salman S, Nha L, V. Patai Á, Hajiani E, Abravesh AA. Levofloxacin+Tetracycline Quadruple Regimen for Eradication of Helicobacter pylori: A Multicenter Multinational Randomized Controlled Trial. Middle East J Dig Dis 2023; 15:12-18. [PMID: 37547163 PMCID: PMC10404071 DOI: 10.34172/mejdd.2023.314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 10/20/2022] [Indexed: 08/08/2023] Open
Abstract
Background: The ideal combination regimen for Helicobacter pylori (HP) eradication has not yet been determined and the success rate of HP eradication has been extensively reduced worldwide due to increasing antibiotic resistance. So this multinational multi-center randomized controlled trial was designed to evaluate the efficacy of tetracycline +levofloxacin for HP eradication. Methods: During a 6-month period, all of the cases with HP infection in eight referral tertiary centers of three countries were included and randomly allocated to receive either tetracycline + levofloxacin or clarithromycin plus amoxicillin quadruple regimen for two weeks. For all of the participants, pantoprazole was continued for 4 more weeks and after one to two weeks of off-therapy, they underwent urea breath test C13 to prove eradication. Results: Overall 788 patients were included (358 male (45.4%), average age 44.2 years). They were diagnosed as having non-ulcer dyspepsia (516 cases, 65.5%), peptic ulcer disease (PUD) (234 cases, 29.69%), and intestinal metaplasia (38 cases, 4.8%). Racially 63.1% were Caucasian, 14.5% Arab, 15.6% African, and 6.1% Asian. The participants were randomly allocated to groups A and B to receive either tetracycline + levofloxacin or clarithromycin. Among groups A and B in intention to treat (ITT) and per protocol (PP) analysis, 75.2% & 82.1% (285 cases) and 67.5% & 70.1% (276 cases) of participants achieved eradication, respectively (P = 0.0001). The complete compliance rate in groups A and B were 84.4% and 83.6%, respectively. During the study, 33.5% of the participants in group A (127 cases) reported side effects while the complication rate among group B was 27.9% (114 cases, P = 0.041). The most common complaints among groups A and B were nausea and vomiting (12.6% & 9.3%) and abdominal pain (4.48% & 2.68%), respectively. The rate of severe complications that caused discontinuation of medication in groups A and B were 2.1% and 1.46%, respectively (P = 679). In subgroup analysis, the eradication rates of tetracycline+levofloxacin among patients with non-ulcer dyspepsia, PUD, and intestinal metaplasia were 79.4%, 88.1%, and 73.9%, respectively. These figures in group B (clarithromycin base) were 71.3%, 67.6%, and 61.5% respectively (P = 0.0001, 0.0001, and 0.043). Conclusion: Overall, the combination of tetracycline+levofloxacin is more efficient for HP eradication in comparison with clarithromycin+amoxicillin despite more complication rate. In areas with a high rate of resistance to clarithromycin, this therapeutic regimen could be an ideal choice for HP eradication, especially among those who were diagnosed with PUD.
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Affiliation(s)
- Pezhman Alavinejad
- Alimentary Tract Research Center, Imam Khomeini Hospital Clinical Research Development Unit, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- World Endoscopy Organization Emerging Star Group, WEO, Munich, Germany
| | - Morteza Nayebi
- Shahid Rajaie Cardiovascular, Medical & Research Center, Tehran, Iran
| | - Abazar Parsi
- Alimentary Tract Research Center, Imam Khomeini Hospital Clinical Research Development Unit, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Eman Abdelsameea
- Assistant Professor of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Egypt
| | - Mohammed Hussien Ahmed
- Lecturer Hepatology Gastroenterology and Infectious Diseases, Faculty of Medicine, Kafrelsheikh University, Cairo, Egypt
| | - Ahmad Hormati
- Gastrointestinal and Liver Diseases Research Center, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Dao Viet Hang
- Lecturer, Internal Medicine Faculty - Hanoi Medical University (HMU), Vietnam
| | - Mehdi Pezeshgi Modarres
- Gastroenterology and Hepatology Disease Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Bahman Cheraghian
- Alimentary Tract Research Center, Imam Khomeini Hospital Clinical Research Development Unit, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Siamak Baghaee
- Alimentary Tract Research Center, Imam Khomeini Hospital Clinical Research Development Unit, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Ahvaz Branch, Islamic Azad University, Ahvaz, Iran
| | - Tahmine Farbod Ara
- Alimentary Tract Research Center, Imam Khomeini Hospital Clinical Research Development Unit, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Quang Trung Tran
- World Endoscopy Organization Emerging Star Group, WEO, Munich, Germany
- Department of Internal Medicine, University of Medicine and Pharmacy, Hue University, Vietnam
- Department of Internal Medicine A, Greifswald University of Medicine, Greifswald, Germany
| | - Nitin Shanker Behl
- Institute of Gastro and Liver Diseases, Fortis Hospital, Ludhiana, India
| | - Seyed Jalal Hashemi
- Alimentary Tract Research Center, Imam Khomeini Hospital Clinical Research Development Unit, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammed Alboraie
- World Endoscopy Organization Emerging Star Group, WEO, Munich, Germany
- Department of Internal Medicine, Al-Azhar University, Cairo, Egypt
| | - Saif Salman
- Hashemite University, Faculty of Medicine, Alzarqa, Jordan
| | - Le Nha
- Gastroenterology Division, Internal Medicine and Hematology Department, Semmelweis University, Budapest, Hungary
| | - Árpád V. Patai
- Gastroenterology Division, Internal Medicine and Hematology Department, Semmelweis University, Budapest, Hungary
- Interdisciplinary Gastroenterology Working Group, Semmelweis University, Budapest, Hungary
| | - Eskandar Hajiani
- Alimentary Tract Research Center, Imam Khomeini Hospital Clinical Research Development Unit, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Akbar Abravesh
- Alimentary Tract Research Center, Imam Khomeini Hospital Clinical Research Development Unit, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Burgos-Santamaría D, Nyssen OP, Gasbarrini A, Vaira D, Pérez-Aisa Á, Rodrigo L, Pellicano R, Keco-Huerga A, Pabón-Carrasco M, Castro-Fernandez M, Boltin D, Barrio J, Phull P, Kupcinskas J, Jonaitis L, Ortiz-Polo I, Tepes B, Lucendo AJ, Huguet JM, Areia M, Jurecic NB, Denkovski M, Bujanda L, Ramos-San Román J, Cuadrado-Lavín A, Gomez-Camarero J, Jiménez Moreno MA, Lanas A, Martinez-Dominguez SJ, Alfaro E, Marcos-Pinto R, Milivojevic V, Rokkas T, Leja M, Smith S, Tonkić A, Buzás GM, Doulberis M, Venerito M, Lerang F, Bordin DS, Lamy V, Capelle LG, Marlicz W, Dobru D, Gridnyev O, Puig I, Mégraud F, O'Morain C, Gisbert JP. Empirical rescue treatment of Helicobacter pylori infection in third and subsequent lines: 8-year experience in 2144 patients from the European Registry on H. pylori management (Hp-EuReg). Gut 2022; 72:gutjnl-2022-328232. [PMID: 36591610 DOI: 10.1136/gutjnl-2022-328232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 11/06/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To evaluate the use, effectiveness and safety of Helicobacter pylori empirical rescue therapy in third and subsequent treatment lines in Europe. DESIGN International, prospective, non-interventional registry of the clinical practice of European gastroenterologists. Data were collected and quality reviewed until October 2021 at Asociación Española de Gastroenterología-Research Electronic Data Capture. All cases with three or more empirical eradication attempts were assessed for effectiveness by modified intention-to-treat and per-protocol analysis. RESULTS Overall, 2144 treatments were included: 1519, 439, 145 and 41 cases from third, fourth, fifth and sixth treatment lines, respectively. Sixty different therapies were used; the 15 most frequently prescribed encompassed >90% of cases. Overall effectiveness remained <90% in all therapies. Optimised treatments achieved a higher eradication rate than non-optimised (78% vs 67%, p<0.0001). From 2017 to 2021, only 44% of treatments other than 10-day single-capsule therapy used high proton-pump inhibitor doses and lasted ≥14 days. Quadruple therapy containing metronidazole, tetracycline and bismuth achieved optimal eradication rates only when prescribed as third-line treatment, either as 10-day single-capsule therapy (87%) or as 14-day traditional therapy with tetracycline hydrochloride (95%). Triple amoxicillin-levofloxacin therapy achieved 90% effectiveness in Eastern Europe only or when optimised. The overall incidence of adverse events was 31%. CONCLUSION Empirical rescue treatment in third and subsequent lines achieved suboptimal effectiveness in most European regions. Only quadruple bismuth-metronidazole-tetracycline (10-day single-capsule or 14-day traditional scheme) and triple amoxicillin-levofloxacin therapies reached acceptable outcomes in some settings. Compliance with empirical therapy optimisation principles is still poor 5 years after clinical practice guidelines update. TRIAL REGISTRATION NUMBER NCT02328131.
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Affiliation(s)
- Diego Burgos-Santamaría
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Enfermedades Hepáticas y Digestivas, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Olga P Nyssen
- Gastroenterology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Madrid, Spain
- Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Antonio Gasbarrini
- Internal Medicine, Gastroenterology and Liver Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Roma, Italy
| | - Dino Vaira
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Ángeles Pérez-Aisa
- Department of Gastroenterology, Hospital Costa del Sol Marbella, Marbella, Spain
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Marbella, Spain
| | - Luís Rodrigo
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Rinaldo Pellicano
- Outpatient Clinic, Molinette-SGAS Hospital, University of Turin, Turin, Italy
| | | | | | - Manuel Castro-Fernandez
- Hospital Universitario Virgen de Valme, Sevilla, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Sevilla, Spain
| | - Doron Boltin
- Department of Gastroenterology, Rabin Medical Center, Beilinson Campus, Tel Aviv University, Petach Tikva, Israel
| | - Jesus Barrio
- Department of Gastroenterology, Hospital Rio Hortega, Valladolid, Spain
| | | | - Juozas Kupcinskas
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Laimas Jonaitis
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Inmaculada Ortiz-Polo
- Department of Gastroenterology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Bojan Tepes
- Department of Gastroenterology, AM DC Rogaska, Rogaska Slatina, Slovenia
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - José María Huguet
- Gastroenterology Unit, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Miguel Areia
- Francisco Gentil Portuguese Institute for Oncology of Coimbra, Coimbra, Portugal
| | | | | | - Luís Bujanda
- Department of Gastroenterology, Hospital Universitario de Donostia, San Sebastian, Spain
- Instituto Biodonostia, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), San Sebastián, Spain
| | - June Ramos-San Román
- Department of Gastroenterology, Hospital Universitario de Donostia, San Sebastian, Spain
| | - Antonio Cuadrado-Lavín
- Department of Gastroenterology and Hepatology, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | | | | | - Angel Lanas
- Department of Gastroenterology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | | | - Enrique Alfaro
- Department of Gastroenterology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Ricardo Marcos-Pinto
- Department of Gastroenterology, Centro Hospitalar do Porto, Porto, Portugal
- CINTESIS, University of Porto Institute of Biomedical Sciences Abel Salazar, Porto, Portugal
| | - Vladimir Milivojevic
- University Clinical Center of Serbia Clinic for Gastroenterology and Hepatology, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Theodore Rokkas
- Department of Gastroenterology, Henry Dunant Hospital Center, Athens, Greece
| | - Marcis Leja
- Digestive Disease Center GASTRO, Institute of Clinical and Preventive Medicine, Riga, Latvia
- University of Latvia Faculty of Medicine, Riga, Latvia
| | - Sinead Smith
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Ante Tonkić
- Department of Gastroenterology, University Hospital Center Split Križine, Split, Croatia
| | - György Miklós Buzás
- Department of Gastroenterology, Ferencváros Health Centre, Budapest, Hungary
| | - Michael Doulberis
- Division of Gastroenterology and Hepatology, Kantonsspital Aarau AG, Aarau, Switzerland
- Department of Gastroenterology and Hepatology, University of Zurich, Zurich, Switzerland
| | - Marino Venerito
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Frode Lerang
- Department of Gastroenterololgy, Ostfold Hospital, Gralum, Norway
| | - Dmitry S Bordin
- Department of Pancreatic, Biliary and Upper Digestive Tract disorders, AS Loginov Moscow Clinical Scientific Center, Moscow, Russian Federation
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | | | - Lisette G Capelle
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Wojciech Marlicz
- Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - Daniela Dobru
- Department of Gastroenterology, University of Medicine, Pharmacy, Science, and Technology of Târgu Mures, Târgu Mures, Romania
| | | | - Ignasi Puig
- Department of Digestive Diseases, Althaia, Xarxa Assistencial Universitària de Manresa, Manresa, Spain
- Universitat de Vic-Universitat Central de Catalunya (UVicUCC), Manresa, Spain
| | | | - Colm O'Morain
- Department of Gastroenterology, Trinity College Dublin, Dublin, Ireland
| | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Madrid, Spain
- Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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Multiple Bismuth Quadruple Therapy Containing Tetracyclines Combined with Other Antibiotics and Helicobacter pylori Eradication Therapy. J Clin Med 2022; 11:jcm11237040. [PMID: 36498615 PMCID: PMC9741466 DOI: 10.3390/jcm11237040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/24/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Helicobacter pylori (HP) infection is closely associated with the development of chronic gastritis, peptic ulcer, and gastric cancer. However, the resistance rate of H. pylori strains to antibiotics such as clarithromycin, metronidazole, and levofloxacin has increased significantly, resulting in a significant decrease in the eradication efficacy of commonly used regimens. Tetracycline has received the attention of domestic and foreign scholars because of its low resistance. The purpose of this review is to provide an update on the tetracycline-containing bismuth quadruple eradication therapy for H. pylori infection and review the efficacy and safety of the regimens, hoping to provide guidance for clinical practice.
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Xu X, He C, Zhu Y. Treatment of refractory Helicobacter pylori infection: A new challenge for clinicians. Front Microbiol 2022; 13:998240. [PMID: 36329840 PMCID: PMC9623003 DOI: 10.3389/fmicb.2022.998240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/20/2022] [Indexed: 11/23/2022] Open
Abstract
Patients who have failed two or more attempts to eradicate Helicobacter pylori are commonly referred to as refractory. Although the incidence of refractory Helicobacter pylori infection is only 10–20%, with the increasing rate of antibiotic resistance in various regions, the treatment of refractory Helicobacter pylori infection has gradually become a difficult problem faced by clinicians. When choosing a rescue therapy, the physician must consider numerous factors. A longer treatment duration, higher doses of proton pump inhibitors (PPIs), or the use of potassium-competitive acid blocker (P-CAB) may increase the efficacy of triple therapy or bismuth quadruple therapy. Rescue treatment based on bismuth quadruple therapy usually achieves better results. At the same time, treatment based on drug susceptibility tests or genotypic resistance is recommended where available. Of course, appropriate empiric treatment can also be selected according to local drug resistance, a patient’s previous medication history and compliance. It is the best choice if it can improve the success rate of the first treatment and reduce the occurrence of refractory Helicobacter pylori infection. This review aims to summarize the articles related to refractory Helicobacter pylori in recent years and to explore a better remedial treatment plan for clinicians.
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7
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Malfertheiner P, Megraud F, Rokkas T, Gisbert JP, Liou JM, Schulz C, Gasbarrini A, Hunt RH, Leja M, O'Morain C, Rugge M, Suerbaum S, Tilg H, Sugano K, El-Omar EM. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut 2022; 71:gutjnl-2022-327745. [PMID: 35944925 DOI: 10.1136/gutjnl-2022-327745] [Citation(s) in RCA: 316] [Impact Index Per Article: 158.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/21/2022] [Indexed: 01/06/2023]
Abstract
Helicobacter pyloriInfection is formally recognised as an infectious disease, an entity that is now included in the International Classification of Diseases 11th Revision. This in principle leads to the recommendation that all infected patients should receive treatment. In the context of the wide clinical spectrum associated with Helicobacter pylori gastritis, specific issues persist and require regular updates for optimised management.The identification of distinct clinical scenarios, proper testing and adoption of effective strategies for prevention of gastric cancer and other complications are addressed. H. pylori treatment is challenged by the continuously rising antibiotic resistance and demands for susceptibility testing with consideration of novel molecular technologies and careful selection of first line and rescue therapies. The role of H. pylori and antibiotic therapies and their impact on the gut microbiota are also considered.Progress made in the management of H. pylori infection is covered in the present sixth edition of the Maastricht/Florence 2021 Consensus Report, key aspects related to the clinical role of H. pylori infection were re-evaluated and updated. Forty-one experts from 29 countries representing a global community, examined the new data related to H. pylori infection in five working groups: (1) indications/associations, (2) diagnosis, (3) treatment, (4) prevention/gastric cancer and (5) H. pylori and the gut microbiota. The results of the individual working groups were presented for 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 various clinical fields.
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Affiliation(s)
- Peter Malfertheiner
- Medical Department 2, LMU, Munchen, Germany
- Department of Radiology, LMU, Munchen, Germany
| | - Francis Megraud
- INSERM U853 UMR BaRITOn, University of Bordeaux, Bordeaux, France
| | - Theodore Rokkas
- Gastroenterology, Henry Dunant Hospital Center, Athens, Greece
- Medical School, European University, Nicosia, Cyprus
| | - Javier P Gisbert
- Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Jyh-Ming Liou
- Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Christian Schulz
- Medical Department 2, LMU, Munchen, Germany
- Partner Site Munich, DZIF, Braunschweig, Germany
| | - Antonio Gasbarrini
- Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Roma, Italy
| | - Richard H Hunt
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - Marcis Leja
- Faculty of Medicine, University of Latvia, Riga, Latvia
- Institute of Clinical and Preventive Medicine, University of Latvia, Riga, Latvia
| | - Colm O'Morain
- Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Massimo Rugge
- Department of Medicine (DIMED), Surgical Pathology & Cytopathology Unit, University of Padova, Padova, Italy
- Veneto Tumor Registry (RTV), Padova, Italy
| | - Sebastian Suerbaum
- Partner Site Munich, DZIF, Braunschweig, Germany
- Max von Pettenkofer Institute, LMU, Munchen, Germany
| | - Herbert Tilg
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology & Metabolism, Medizinische Universitat Innsbruck, Innsbruck, Austria
| | - Kentaro Sugano
- Department of Medicine, Jichi Medical School, Tochigi, Japan
| | - Emad M El-Omar
- Department of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
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8
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Gisbert JP, Alcedo J, Amador J, Bujanda L, Calvet X, Castro-Fernández M, Fernández-Salazar L, Gené E, Lanas Á, Lucendo AJ, Molina-Infante J, Nyssen OP, Pérez-Aisa A, Puig I. V Spanish Consensus Conference on Helicobacter pylori infection treatment. GASTROENTEROLOGIA Y HEPATOLOGIA 2022; 45:392-417. [PMID: 34629204 DOI: 10.1016/j.gastrohep.2021.07.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/30/2021] [Accepted: 07/16/2021] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| | - Javier Alcedo
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, España
| | - Javier Amador
- Medicina de Familia, Centro de Salud Los Ángeles, Dirección Asistencial Centro, SERMAS, Madrid, España
| | - Luis Bujanda
- Servicio de Aparato Digestivo, Hospital Donostia/Instituto Biodonostia, Universidad del País Vasco UPV/EHU, CIBEREHD, San Sebastián, España
| | - Xavier Calvet
- Servicio de Aparato Digestivo, Hospital Parc Taulí, Universitat Autónoma de Barcelona, CIBEREHD, Sabadell, Barcelona, España
| | | | - Luis Fernández-Salazar
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud (SACYL), Universidad de Valladolid, Valladolid, España
| | - Emili Gené
- Servicio de Urgencias, Hospital Parc Taulí Sabadell, CIBEREHD, Universitat Internacional de Catalunya, Barcelona, España
| | - Ángel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Zaragoza, Instituto de Investigación Sanitaria de Aragón (IIS Aragón), CIBEREHD, Zaragoza
| | - Alfredo J Lucendo
- Servicio de Aparato Digestivo, Hospital General de Tomelloso, CIBEREHD, Ciudad Real, España
| | - Javier Molina-Infante
- Servicio de Aparato Digestivo, Hospital Universitario de Cáceres, CIBEREHD, Cáceres, España
| | - Olga P Nyssen
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España
| | - A Pérez-Aisa
- Servicio de Aparato Digestivo, Agencia Sanitaria Costa del Sol, Marbella, Málaga, España
| | - Ignasi Puig
- Servicio de Aparato Digestivo, Althaia Xarxa Assistencial Universitària de Manresa, Universitat de Vic-Universitat Central de Catalunya (UVicUCC), Manresa, Barcelona, España
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9
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Valladales-Restrepo LF, Correa-Sánchez Y, Aristizábal-Carmona BS, Machado-Alba JE. Treatment regimens used in the management of Helicobacter pylori in Colombia. Braz J Infect Dis 2022; 26:102331. [PMID: 35182470 PMCID: PMC9387446 DOI: 10.1016/j.bjid.2022.102331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/01/2021] [Accepted: 01/01/2022] [Indexed: 11/28/2022] Open
Abstract
Background Helicobacter pylori infection can cause gastritis, gastric ulcers, duodenal ulcers, and gastric cancer. Its treatment involves different medications, but resistance to these treatments is increasing. It is currently considered a public health problem. Aims to identify regimens used for H. pylori eradication by age group, year of treatment and geographical region of Colombia. Methods A cross-sectional study that identified regimens used H. pylori eradication in outpatient consultations over a 6-year period based on a medication dispensing database of 8.5 million people affiliated to the Colombian Health System. The appropriate regimens were those that included a proton pump inhibitor, associated with two antibiotics recommended by clinical practice guidelines (amoxicillin, clarithromycin, levofloxacin, moxifloxacin, tetracycline, doxycycline, metronidazole, tinidazole, and furazolidone). Results A total of 12,011 patients with a diagnosis of acid-peptic disease and H. pylori infection were identified, who had undergone 12,426 eradication treatment courses. Of these, 98.0% used a proton pump inhibitor (PPI), and 91.1% used amoxicillin. A total of 56.1% of the regimens were considered adequate; of these, 42.0% were a combination of PPI, amoxicillin/clarithromycin. This regimen predominated between 2015 and 2017 for all age groups. Conclusions The management of H. pylori infection in the majority of patients is heterogeneous and inconsistent with current recommendations based on evidence of antimicrobial resistance.
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Graham DY. Transitioning of Helicobacter pylori Therapy from Trial and Error to Antimicrobial Stewardship. Antibiotics (Basel) 2020; 9:E671. [PMID: 33023041 PMCID: PMC7601139 DOI: 10.3390/antibiotics9100671] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 09/28/2020] [Accepted: 10/01/2020] [Indexed: 12/21/2022] Open
Abstract
Helicobacter pylori is the only major infection for which antimicrobial therapy is not designed using the principles of antimicrobial stewardship. Traditionally, antimicrobial therapy is a susceptibility-based therapy, achieves high cure rates, and includes surveillance programs to regularly provide updated data regarding resistance, outcomes, and treatment guidelines. Current H. pylori therapies identified by trial-and-error, and treatment recommendations and guidelines are based on comparisons among regimens that rarely take into account the prevalence or effect of resistance. The majority of patients currently treated achieve suboptimal results. A paradigm shift is required to abandon current approaches and embrace antimicrobial stewardship, and therefore reliably achieve high cure rates; develop, propagate, and update best practice guidelines; and provide surveillance of local or regional susceptibility/resistance patterns. These also require timely updates to clinicians regarding the current status of resistance, antimicrobial effectiveness, and ways to prevent antimicrobial misuse to extend the useful life of currently available antibiotics. Here, we discuss the differences among current approaches to H. pylori therapy and antimicrobial stewardship and identify what is required to achieve the transition. Conceptually, the differences are significant, and the transition will likely need to be both abrupt and complete. Recommendations for therapy during the transition period are given.
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Affiliation(s)
- David Y Graham
- Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, RM 3A-318B (111D), 2002 Holcombe Boulevard, Houston, TX 77030, USA
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