Comparison of the efficacy of the two tetracycline-containing sequential therapy regimens for the eradication of Helicobacter pylori: 5 days versus 14 days amoxicillin

Primary and secondary antibiotic resistance of Helicobacter pylori in Korea from 2003 to 2018

BACKGROUND

Antimicrobial resistance of Helicobacter pylori (H pylori) affects the efficacy of eradication therapy. The aim of this study was to estimate the prevalence of primary and secondary resistance of H pylori isolates to antibiotics in Korea.

METHODS

The present study was performed from 2003 to 2018. Primary resistance was evaluated in 591 patients without any history of eradication and secondary resistance in 149 patients from whom Helicobacter pylori was cultured after failure of eradication. A minimal inhibitory concentration test was performed for amoxicillin, clarithromycin, metronidazole, tetracycline, levofloxacin, and rifabutin using the agar dilution method.

RESULTS

An increase in the primary resistance rate was found in clarithromycin (P < .001), metronidazole (P < .001), and both levofloxacin (P < .001) during the study period. The primary resistance rates of amoxicillin and tetracycline were low and stable during the study period. The secondary resistance rate significantly increased in metronidazole and levofloxacin (P = .022 and .039, respectively).

CONCLUSIONS

The primary and secondary resistance rates of clarithromycin, metronidazole, and levofloxacin for Helicobacter pylori in Korea were high and increased over time. However, the primary and secondary resistance rates of amoxicillin and tetracycline were low and stable over time. These results will help in selecting effective eradication regimens of H pylori in Korea in the future.

Comparison of sequential therapy and amoxicillin/tetracycline containing bismuth quadruple therapy for the first-line eradication of Helicobacter pylori: a prospective, multi-center, randomized clinical trial

BACKGROUND

The <80 % Helicobacter pylori eradication rate with sequential therapy is unsatisfactory. Modified bismuth quadruple therapy, replacing metronidazole with amoxicillin, could be promising because H. pylori resistance to tetracycline or to amoxicillin is relatively low. A 14-day modified bismuth quadruple protocol as first-line H. pylori treatment was compared with 10-day sequential therapy.

METHODS

In total, 390 H. pylori-infected subjects participated in the randomized clinical trial: 10-day sequential therapy (40 mg pantoprazole plus 1 g amoxicillin twice a day for 5 days, then 40 mg pantoprazole and 500 mg clarithromycin twice a day and 500 mg metronidazole three times a day for 5 days) or 14-day modified bismuth quadruple therapy (40 mg pantoprazole, 600 mg bismuth subcitrate, 1 g tetracycline, and 1 g amoxicillin, twice a day). (13)C-urea breath test, rapid urease testing, or histology was performed to check for eradication.

RESULTS

Intention-to-treat (ITT) eradication rates of 10-day sequential and 14-day quadruple therapy were 74.6 % and 68.7 %, respectively, and the per-protocol (PP) rates were 84.2 and 76.5 %, respectively. The eradication rate was higher in the sequential therapy group, but neither the ITT nor the PP analyses had a significant difference (P = 0.240 and P = 0.099, respectively). However, the adverse events were significantly lower in the modified bismuth quadruple therapy group than the sequential therapy group (36.9 vs. 47.7 %, P = 0.040).

CONCLUSIONS

Ten-day sequential therapy appears to be more effective despite frequent adverse events. However, both 10-day SQT and 14-day PBAT did not reach the excellent eradication rates that exceed 90 %. Additional trials are needed to identify a more satisfactory first-line eradication therapy.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT02159976 ); Registration date: 2014-06-03, CRIS ( KCT0001176 ); Registration date: 2014-07-23.

Helicobacter pylori treatment: Still a work in progress

Helicobacter pylori is a common worldwide bacterium, possessing adaptability that has created difficulty achieving eradication. While the standard treatment was thought to be triple therapy with a proton pump inhibitor, amoxicillin, and clarithromycin, growing rates of treatment failure and antibiotic resistance have stimulated research into novel regimens. Quadruple therapy with bismuth has been compared for both first- and second-line treatments, but eradication still has not reached expected goals. Innovative regimens including sequential and concomitant therapy, as well as the introduction of new antibiotics into previous treatment schedules, have shown promising improvements in eradication rates. We discuss and compare these unique regimens, reviewing the current literature to deduce those which are most likely to provide the highest success in curing H. pylori infection.

Review: efficacy and safety of hybrid therapy for Helicobacter pylori infection: a systematic review and meta-analysis

OBJECTIVES

To assess the efficacy and safety of hybrid therapy compared to other pre-existing therapies and to new therapies.

METHODS

Through a search of PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and Conference Proceedings Citation Index, two independent reviewers systemically identified randomized, controlled trials that compared hybrid therapy to other pre-existing and new therapies. Dichotomous data were pooled to obtain the relative risk (RR) of the eradication rate, with 95% confidence intervals (CIs).

RESULTS

We identified 6 studies, 5 of which compared hybrid therapy and sequential therapy, and 3 of which compared hybrid therapy and concomitant therapy. Pooled estimates of the 5 randomized controlled trials (RCTs) revealed no significant differences between hybrid therapy and sequential therapy and no evidence of heterogeneity (I(2)  = 0%; p = .803), the pooled RRs were 1.02 (95% CI: 0.93-1.12) (intention-to-treat (ITT)), and 1.03 (95% CI: 0.94-1.13) (per protocol (PP)). Pooled estimates of the 3 RCTs showed no significant differences between hybrid therapy and concomitant therapy with no evidence of heterogeneity (I(2)  = 0%; p = .967), the pooled RRs were 0.99 (95% CI: 0.89-1.10) (ITT) and 0.99 (95% CI: 0.89-1.10) (PP). No significant differences in adverse events were noted among hybrid therapy, sequential therapy, and concomitant therapy ((RR: 1.13; 95% CI: 0.87-1.48; I(2)  = 13.2%; p = .327), (RR: 0.89; 95% CI: 0.73-1.08; I(2)  = 0%; p = .978) (ITT), respectively). After consideration of all treatment arms, the ITT eradication rates with hybrid therapy, concomitant therapy, and sequential therapy were 88.6, 86.3, and 84.7%, respectively. And the PP eradication rates were 92.1, 92.5, and 87.5%. No significant differences were observed between the groups in terms of compliance.

CONCLUSIONS

All three of these therapies yielded good eradication rates. Hybrid therapy could be an alternative to sequential therapy and concomitant therapy, but additional RCTs are needed to confirm this finding.

Meta-analysis: Is combination of tetracycline and amoxicillin suitable for Helicobacter pylori infection?

AIM: To access the efficacy of combination with amoxicillin and tetracycline for eradication of Helicobacter pylori (H. pylori), thus providing clinical practice guidelines.

METHODS: PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Science Citation Index, China National Knowledge Infrastructure, Wanfang, and Chinese Biomedical Literature databases and abstract books of major European, American, and Asian gastroenterological meetings were searched. All clinical trials that examined the efficacy of H. pylori eradication therapies and included both tetracycline and amoxicillin in one study arm were selected for this systematic review and meta-analysis. Statistical analysis was performed with Comprehensive Meta-Analysis Software (Version 2). Subgroup, meta-regression, and sensitivity analyses were also carried out.

RESULTS: Thirty-three studies met the inclusion criteria. The pooled odds ratio (OR) was 0.90 (95%CI: 0.42-1.78) for quadruple therapy with amoxicillin and tetracycline vs other quadruple regimens, and total eradication rates were 78.1% by intention-to-treat (ITT) and 84.5% by per-protocol (PP) analyses in the experimental groups. The pooled eradication rates of 14-d quadruple regimens with a combination of amoxicillin and tetracycline were 82.3% by ITT and 89.0% by PP, and those of 10-d regimens were 84.6% by ITT and 93.7% by PP. The OR by ITT were 1.21 (95%CI: 0.64-2.28) for triple regimens with amoxicillin and tetracycline vs other regimens and 1.81 (95%CI: 1.37-2.41) for sequential treatment with amoxicillin and tetracycline vs other regimens, respectively.

CONCLUSION: The effectiveness of regimens employing amoxicillin and tetracycline for H. pylori eradication may be not inferior to other regimens, but further study should be necessary.

Pharmacological therapy used in the elimination of Helicobacter pylori infection: A review

The optimal therapy for Helicobacter pylori (H. pylori) infection should combine a high cure rate and a short treatment duration with a favorable side-effect profile and should maintain a low cost. Several strategies have been proposed to increase the H. pylori eradication rate, including the extension of the treatment duration to 14 d, the use of a four-drug regimen (quadruple, sequential, and concomitant treatments), and the use of novel antibiotics, such as levofloxacin. However, triple therapy remains the most widely accepted first-line treatment regimen in Brazil and the United States and throughout Europe. Because this therapy is limited by resistance to clarithromycin, other therapeutic regimens have been investigated worldwide. This review describes the current literature involving studies directly comparing these different therapies and their efficacies.

Helicobacter pylori eradication in West Asia: a review

The efficacy of first- and second-line Helicobacter pylori (H. pylori) eradication regimens varies considerably in West Asian countries, mainly due to the variable prevalence of resistant organisms. However, no review article has yet evaluated and compared the efficacy of different regimens among different countries of this region. Therefore, we conducted a review to select the best options and provide recommendations for H. pylori treatment in this geographic region. A search through PubMed was carried out to obtain relevant randomized clinical trials published in English language up to June 2013. According to the results, among different therapeutic regimens used as the first-line protocols, 10-d Bismuth-Furazolidone/Metronidazole quadruple therapy, 14-d Clarithromycin-containing hybrid therapy and 14-d quadruple therapy including a proton pump inhibitor + Bismuth + Tetracycline (500 mg QID) + Metronidazole (500 mg TDS) seemed to be appropriate options. Among second-line therapeutic regimens, Bismuth-based quadruple therapies containing Tetracycline and Furazolidone/Metronidazole, triple therapy containing Amoxicillin and Gatifloxacin and Quadruple therapy including Bismuth + Azithromycin and Ofloxacin seemed to be effective options. Third-line therapies were not evaluated in West Asia; most guidelines, however, recommend choosing optimal eradication regimen according to the pattern of antibiotic susceptibility of H. pylori. Although we limited our investigation to H. pylori eradication regimens in West Asia, the clinical significance of the results goes beyond the countries situated in this geographic region. In fact, the results are transferrable to any region as long as the patterns of resistance are the same.

Comparison of Helicobacter pylori eradication rates of standard 14-day quadruple treatment and novel modified 10-day, 12-day and 14-day sequential treatments

BACKGROUND & AIM

This study aimed to compare the efficacy and safety of bismuth-included standard regimen and modified sequential treatments in Turkey, where the success rate of standard triple therapy is very low.

METHODS

One-hundred and sixty patients with dyspeptic complaints and naïve Helicobacter pylori infection were randomized into four groups: 41 patients received standard 14-day quadruple treatment (STD) (Rabeprazole 20mg-bid, bismuth subcitrate (120 mg-qid), Tetracycline 500 mg-qid, Metronidazole 500 mg-tid) for 2 weeks. The modified sequential therapy groups received 20 mg rabeprazole and 1g amoxicillin, twice daily for the first 5 days, followed by Rabeprazole 20mg-bid, bismuth subcitrate (120 mg-qid), Tetracycline 500 mg-qid, Metronidazole 500 mg-tid for the remaining 5 (10 day sequential therapy group-10S) (42 patients), 7 (12 day sequential therapy group-12S) (42 patients) and 9 (14 day sequential therapy group-14S) (41 patients) days.

RESULTS

The overall compliance and H. pylori eradication rate among the 160 patients who completed the H. pylori eradication regimens were 86.9% (139/160) and 78.1% (125/160), respectively. The results were not statistically different between groups in the eradication rates. Per-protocol eradication rates were 76.5% in STD, 71.4% in 10S, 82.4% in 12S and 83.3% in 14S groups (p=0.7). Intention-to-treatment rates were 77.5% in STD, 72.5% in 10S, 82.5% in 12S and 80.0% in 14S groups (p=0.5).

CONCLUSION

The eradication rates of standard 14-day and different sequential quadruple treatment regimens are comparable and much more higher than with standard 14-day triple H. pylori eradication treatment that has been reported previously in Turkey.

Eradication of Helicobacter pylori infection: which regimen first?

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

Modified sequential therapy regimens for Helicobacter pylori eradication: a systematic review

BACKGROUND

Different modified sequential therapies have been proposed for Helicobacter pylori eradication. However, the efficacy of these regimens is controversial.

METHODS

We performed a systematic review of the literature and pooled-data analysis to assess: (a) the efficacy of different modified sequential therapies for H. pylori eradication, (b) the eradication rates achieved by these regimens as compared to either standard triple therapies or standard sequential regimen when available.

RESULTS

Overall 21 trials met inclusion criteria. The most used modified sequential therapy was the seven plus seven tetracycline-based regimen which achieved an overall 73.3% eradication rate (6 trials). Such therapy was more effective than the 14-day triple therapy (77.2% vs. 63.6%; 3 trials). The most used five plus five levofloxacin-based sequential therapy achieved a 95.8% and 90% cure rates when 250 mg and 500 mg levofloxacin twice daily were used, respectively. These success rates were higher as compared to that of either standard sequential or triple therapies. Other modified sequential therapies did not achieved acceptably high cure rates. Contradictory results emerged from 2 studies assessing the efficacy of a levofloxacin-based sequential regimen as a second-line therapy.

CONCLUSIONS

Both levofloxacin- and tetracycline-based sequential therapies have been proved to be more effective than standard triple therapies, confirming that the 'sequential' administration of drugs is a successful therapeutic procedure for H. pylori infection.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ten-day sequential versus triple therapy for Helicobacter pylori eradication: a prospective, open-label, randomized trial

BACKGROUND AND AIM

Increased resistance of Helicobacter pylori to antibiotics has increased the need to develop new first-line treatments for H. pylori. We have prospectively evaluated 10-day sequential versus conventional triple therapy in peptic ulcer patients.

METHODS

One hundred and fifty-nine patients with peptic ulcer diseases were prospectively randomized to receive 10 days of lansoprazole, amoxicillin, and clarithromycin (conventional triple therapy) or 5 days of lansoprazole and amoxicillin followed by 5 days of lansoprazole, clarithromycin, and metronidazole (sequential therapy). Post-treatment H. pylori status was determined by the (13) C-urea breath test. Eradication rates, antibiotic resistance rates by agar dilution method, drug compliance, and side-effects were compared.

RESULTS

The intention-to-treat eradication rates were 75.9% (95% CI 66.5-85.3%, 60/79) in the sequential therapy group and 58.7% (95% CI 47.9-69.5%, 47/80) in the conventional triple therapy group (P = 0.01), while the per-protocol eradication rates were 86.8% (95% CI 78.7-94.8%, 59/68) and 67.6% (95% CI 56.5-78.7%, 46/68) (P = 0.01), respectively. Compliance and side-effects were similar in the two groups. Culture of H. pylori showed that 18.2% were resistant to clarithromycin, 41.9% to metronidazole. Dual resistance to both antibiotics was 9.6%.

CONCLUSIONS

Although 10-day sequential therapy yielded a higher H. pylori eradication rate than 10-day conventional triple therapy, the sequential therapy protocol did not result in a sufficiently satisfactory eradication rate. This might be related to the higher antibiotics resistance rate especially to dual resistance. More effective regimens are needed to overcome antibiotic resistance in Korea.

Comparison of sequential and standard therapy for Helicobacter pylori eradication in children and investigation of clarithromycin resistance

AIMS

The aim of the present study was to compare the efficacy of sequential and standard triple-drug regimen for Helicobacter pylori (H pylori) eradication in children and to determine the primary resistance rate to clarithromycin.

METHODS

Children with H pylori infection randomized to receive either standard regimen (n = 28) consisting of lansoprazole for 30 days, amoxicillin and clarithromycin for 14 days or sequential regimen (n = 16) consisting of lansoprazole for 30 days, amoxicillin for 7 days, followed by clarithromycin and metronidazole for the next 7 days. Clarithromycin susceptibility of H pylori was assessed with fluorescence in-situ hybridization technique. Eradication was controlled by C urea breath test or monoclonal stool antigen test 4 weeks after the end of the therapy.

RESULTS

H pylori eradication rate was higher in the sequential therapy group (93.7%), compared with the standard therapy group (46.4%) (P = 0.002). There was no difference in adverse drug reactions and in compliance to the treatment between the groups. Primary clarithromycin resistance rate for H pylori was found as 25.7% (n = 9). All of the patients having clarithromycin resistance were coincidentally in the standard therapy group. After the exclusion of these 9 patients, sequential therapy was again found to be more effective than the standard therapy (P = 0.02).

CONCLUSIONS

Sequential therapy seems highly effective for eradicating H pylori in children; however, the difference between 2 groups in resistant strains was the limitation of the study. Our country needs to reassess the effectiveness of standard triple therapy regimen for H pylori eradication.

Helicobacter pylori therapy: Present and future

Helicobacter pylori (H. pylori) plays a crucial role in the pathogenesis of chronic active gastritis, peptic ulcer and gastric mucosa-associated lymphoid tissue-lymphoma, and is also involved in carcinogenesis of the stomach. H. pylori treatment still remains a challenge for physicians, since no current first-line therapy is able to cure the infection in all treated patients. Several factors may help in the eradication of therapy failure. We reviewed both bacterial and host factors involved in therapeutic management of the H. pylori infection. In addition, we evaluated data on the most successful therapy regimens - sequential and concomitant therapies - currently available for H. pylori eradication.

Treatment of Helicobacter pylori infection 2011

This article reviews the literature published pertaining to Helicobacter pylori eradication over the last year. The general perception among clinicians and academics engaged in research on H. pylori has been that eradication rates for first-line therapies are falling, although some data published this year have cast doubt on this. The studies published this year have therefore focussed on developing alternative strategies for the first-line eradication of H. pylori. In this regard, clear evidence now exists that both levofloxacin and bismuth are viable options for first-line therapy. The sequential and "concomitant" regimes have also been studied in new settings and may have a role in future algorithms also. In addition, data have emerged that the probiotic Saccharomyces boulardii may be a useful adjunct to antibiotic therapy. Other studies promote individualized therapies based on host polymorphisms, age, and other such demographic factors.

Treatment of Helicobacter pylori infection 2010

It is accepted that the success of Helicobacter pylori eradication treatment using standard triple therapy is declining. Resistance, particularly to clarithromycin, has been shown in numerous countries to be rising to a level where the use of standard triple therapy in its current form may no longer be justified. The two major factors influencing resistance are prior exposure to the antibiotic and compliance with therapy. Regimes based on bismuth and levofloxacin, which had previously been mainly second-line options, are now emerging as superior first-line options. Trials of sequential and concomitant therapies are also showing the usefulness of these treatments in different populations. Options for third and subsequent line therapies include furazolidone and rifabutin-based regimes. Susceptibility testing should be performed to maintain accurate data on resistance levels, and has also clinical utility in difficult to eradicate cases. None of these, however, will be successful unless compliance is improved upon. If compliance is assured and eradication confirmation pursued, it has been repeatedly illustrated that near full eradication is achievable.