A new modified concomitant therapy for Helicobacter pylori eradication in Turkey

Management of Helicobacter Pylori Infection and Effectiveness Rates in Daily Clinical Practice in Spain: 2010–2019

The management and effectiveness of the treatment of Helicobacter pylori infection are heterogeneous worldwide, despite the publication of international consensus conferences and guidelines, which have been widely available for years. The aim of the study was to describe the clinical management and the eradication rates in a region of Southern Europe (Spain). Between 2010 and 2019, we conducted a retrospective analysis of patients with H. pylori infection attended by gastroenterologists in two defined areas of the National Health System in Aragón. We compared the appropriateness of therapies according to guidelines, and described the effectiveness of each treatment. A total of 1644 penicillin non-allergic patients were included. The most prescribed therapy between 2010 and 2013 was the ‘classic’ triple therapy PCA (80%), whereas the ’concomitant’ therapy PCAM was chosen by 90% of the gastroenterologists in 2015. After 2016, the use of the quadruple bismuth-containing therapy in a single capsule (Pylera^®) quickly increased, representing almost half of the overall prescriptions in 2019. Throughout the decade, adherence to guidelines was 76.4% and global efficacy was 70.7% (ITT). Triple therapies’ eradication rates were lower than 70% (ITT), whereas eradication rates with quadruple therapies achieved or were over 80% (ITT). In conclusion, despite the use of quadruple therapies and optimized treatments, the effectiveness of H. pylori management in daily clinical practice is far from the target of 90%.

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.

Efficiency of Diagnostic Testing for Helicobacter pylori Infections-A Systematic Review

Background: The most recommended treatment for a Helicobacter pylori infection is high doses of combined antibiotics. The objective of this article is to perform a systematic review of the economic evaluation studies applied to assess the efficiency of diagnostic testing for H. pylori infections, so that their main characteristics can be identified and to learn from the literature how the antimicrobial resistance (AMR) issue is incorporated into these economic evaluations. Methods: We conducted a systematic review to compare the costs and clinical effectiveness of diagnostic strategies for H. pylori infections. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and extracted the items from the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Results: We found thirteen articles that were of good quality according to CHEERS: six studies focused on diagnostics of Helicobacter pylori infections associated with dyspepsia and four on duodenal ulcers. Testing was found to be the most cost-effective strategy in eight articles. Four studies considered AMR. Conclusions: Testing was more cost-effective than empirical treatment, except in cases of high prevalence (as with developing countries) or when patients could be stratified according to their comorbidities. The introduction of AMR into the model may change the efficiency of the testing strategy.

Helicobacter pylori therapy and clinical perspective

Helicobacter pylori induces chronic gastritis and duodenal ulcer in a small fraction of the colonised population. Three decades after the discovery of H. pylori and disclosure of an urgent need for eliminating the bacterium in patients, it seems that we are still in the first steps of dealing with this mysterious organism. Treatment of H. pylori is a complex dilemma for clinicians, a repeating sentence by many scientists who spend years on this research topic. Apart from many modifications in initial first-line treatment of H. pylori, gastroenterologists are unable to overcome the problem of therapeutic failure. Choosing the best regimen in any region depends on many factors, which have been the focus of many randomised clinical trials. A potential increase in efficacy of future therapies may be influenced by adding the novel potassium-competitive acid blocker vonoprazan. Undeniably, in-depth analysis is necessary to propose more effective therapeutic regimens. Meanwhile, we recommend the performance of antimicrobial susceptibility testing before any antimicrobial prescription.

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.

Optimization strategies aimed to increase the efficacy of H. pylori eradication therapies

BACKGROUND

As with any other infectious disease, we should aim for treatments offering ≥90% Helicobacter pylori eradication rates in clinical practice.

AIM

To summarize optimization strategies aimed to increase the efficacy of H. pylori eradication therapies.

METHODS

A systematic bibliographic search (in PubMed up to August 2016) was designed to identify studies investigating optimization strategies aimed to increase the efficacy of H. pylori eradication therapies.

RESULTS

The most direct way to optimize a treatment is using higher doses of drugs unless it has been shown that lower doses are equally effective. Similarly, prescriptions should use 14-day duration unless a shorter scheme has been shown locally to be equally effective. Double-dose proton-pump inhibitor therapy is recommended for triple therapy and may probably increase the efficacy of nonbismuth concomitant regimen as well. The efficacy of triple therapies in the presence of resistance can be significantly improved by the addition of bismuth salts, which offer an additive effect in combination with antibiotics. Overall, probiotics seem to reduce antibiotic side effects, but the increase in eradication rates is not so evident; therefore, they cannot be generally recommended for clinical practice yet.

CONCLUSIONS

Using potent acid inhibition and/or higher antibiotic doses-especially by increasing the number of daily intakes-and lengthening treatments up to 14 days improves efficacy in most regimens and should be generally recommended. Triple therapies can be efficiently improved by the addition of bismuth salts, turning them into quadruple therapies. Finally, some treatments will require a combination of optimization strategies to significantly improve results.

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.

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.

Antimicrobial Susceptibility-Guided Therapy Versus Empirical Concomitant Therapy for Eradication of Helicobacter pylori in a Region with High Rate of Clarithromycin Resistance

BACKGROUND

Nonbismuth quadruple (concomitant) regimen is recommended for first-line empirical Helicobacter pylori (HP) eradication treatment when clarithromycin resistance is more than 15-20%. Our objective was to evaluate the efficacy and tolerability of concomitant versus antimicrobial susceptibility-guided treatment in an area with high rates of clarithromycin resistance.

METHODS

Three hundred consecutive HP-infected patients received antimicrobial susceptibility-guided therapy or empirical concomitant therapy for 10 days. The concomitant regimen was omeprazole (20 mg/12 hour), amoxicillin (1 g/12 hour), clarithromycin (500 mg/12 hour), and metronidazole (500 mg/12 hour) (OACM). Patients diagnosed by culture received one of three combinations of antibiotics based on susceptibility results: omeprazole, amoxicillin, and clarithromycin (OAC); omeprazole, amoxicillin, and levofloxacin (OAL); or omeprazole, amoxicillin, and metronidazole (OAM), at the aforementioned doses (and 500 mg/12 hour in the case of levofloxacin). Eradication was confirmed with a (13)C urea breath test, 6 weeks after treatment. Adverse events and adherence were assessed with questionnaires and reviewing medication sachets.

RESULTS

The mean age was 50 years, 59% were women, and 14% had peptic ulcers. Concomitant and antimicrobial susceptibility-guided eradication rates were, respectively, 87% and 94% by intention-to-treat (p = .08) and 89% and 95% (p = .08) per protocol per-protocol analysis. Adverse effects were reported in 31% of patients on OACM and 15% of those on susceptibility-guided therapy (p < .05).

CONCLUSIONS

For HP eradication in a region with high rates of multiple drug resistance, antimicrobial susceptibility-guided therapy is more effective than empirical concomitant therapy.

Practical Aspects in Choosing a Helicobacter pylori Therapy

Cure rates greater than 90%-95% should be expected with an antimicrobial therapy for Helicobacter pylori infection. Standard triple therapy does not guarantee these efficacy rates in most settings worldwide anymore. The choice of eradication regimen should be dictated by factors that can predict the outcome: (1) H. pylori susceptibility; (2) patients' history of prior antibiotic therapy; and (3) local data, either resistance patterns or clinical success. Currently, the preferred first-line choices are 14-day bismuth quadruple and 14-day non-bismuth quadruple concomitant therapy. Bismuth quadruple (if not used previously), fluoroquinolone-, furazolidone- and rifabutin-containing regimens might be effective rescue treatments.

The impact of amalgam dental fillings on the frequency of Helicobacter pylori infection and H. pylori eradication rates in patients treated with concomitant, quadruple, and levofloxacin-based therapies

BACKGROUND AND AIM

Mercury exposure is encountered most commonly in individuals with amalgam fillings. The toxic, bactericidal, and immunosuppressive effects of mercury are well known. Furthermore, multiple antibiotic resistance can be transferred, together with mercury resistance. The aim of this study was to investigate the frequency of Helicobacter pylori infection in dyspeptic patients with amalgam fillings and the effect of the amalgam fillings on H. pylori eradication rates in these patients.

PATIENTS AND METHODS

Four hundred and seventy-five patients who presented with dyspeptic complaints and underwent upper gastrointestinal endoscopy and gastric biopsy were included in this study. One hundred and sixty-nine (35.6%) patients were negative and 306 (64.4%) patients were positive for H. pylori. All of the participants underwent dental examinations in a blinded manner. The participants were divided into two groups on the basis of the presence of amalgam fillings. The H. pylori-positive patients were divided randomly into three subgroups: patients who received concomitant therapy (CT) (rabeprazole-amoxicillin-clarithromycin-metronidazole for 14 days; n=122); patients who received quadruple therapy (QT) (rabeprazole-tetracycline-metronidazole-colloidal bismuth subcitrate for 10 days; n=97); and patients who received levofloxacin-based therapy (LT) (rabeprazole-amoxicillin-levofloxacin for 10 days; n=87). Eradication success was detected by a urea breath test 6 weeks after the end of treatment.

RESULTS

The frequency of H. pylori infection was significantly lower in the filling group compared with the nonfilling group (53.7 and 78.8%, respectively; P<0.001). The eradication rates in the CT, QT, and LT groups were 65.5, 67.0, and 58.6%, respectively, in the intention-to-treat (ITT) analysis and 69.6, 70.7, and 62.2%, respectively, in the per-protocol (PP) analysis. In all of the H. pylori-positive patients and separately in the CT and LT groups, the eradication rates were significantly lower in the filling group compared with the nonfilling group. However, in the QT group, there was no significant difference between the patients with and without fillings (P=0.001, 0.003, 0.012, 0.14, respectively). Logistic regression analysis showed that the absence of amalgam filling exerts independent effects on the increased frequency of H. pylori infection and increased rate of H. pylori eradication.

CONCLUSION

This is the first study to show a lower frequency of H. pylori colonization in patients with amalgam fillings than without and that H. pylori eradication rates are lower in patients with amalgam fillings compared to those without.

Optimizing clarithromycin-containing therapy for Helicobacter pylori in the era of antibiotic resistance

The efficacy of triple therapy for Helicobacter pylori infection has dramatically declined over the last decade, largely related to increasing clarithromycin resistance rates. From a microbiological standpoint, bismuth quadruple therapy is the ideal replacement since it combines drugs for which resistance does not impair its efficacy. Nonetheless, several obstacles such as availability, complexity or tolerance prevent a general implementation of bismuth quadruple therapy, so non-bismuth quadruple regimens remain the best first-line treatment in clinical practice in many geographical areas. We review the rationale and efficacy of several optimization tools (increasing the length of duration, high-dose acid suppression, probiotics), which have been largely evaluated over the last 5 years to increase the effectiveness of standard triple therapy. Then, we update available evidence on the effectiveness of several non-bismuth quadruple therapies (sequential, concomitant, hybrid, miscellaneous therapy), which have gained interest lately. We also revise evidence on the efficacy of the aforementioned optimization tools for non-bismuth quadruples schemes and, finally we provide a novel regionalized therapeutic algorithm, based on novel formulas recently developed for predicting the outcome of non-bismuth quadruple regimens, upon local antibiotic resistance rates.

Challenging the dogma: a randomized trial of standard vs. half-dose concomitant nonbismuth quadruple therapy for Helicobacter pylori infection

BACKGROUND

Current treatment of Helicobacter pylori consists of three or four drugs for 7-14 days with important associated cost and adverse events.

AIMS

This study compared efficacy and safety of standard dose vs. half-dose concomitant nonbismuth quadruple therapy (NBQT) for 7 days. The standard dose consisted of twice daily rabeprazole 20 mg, amoxicillin 1 g, metronidazole 500 mg, and clarithromycin 500 mg.

METHODS

This was a prospective randomized trial. (14)C-urea breath test was performed ≥4 weeks after treatment and ≥2 weeks off acid suppressive therapy. Compliance and adverse events were monitored during treatment.

RESULTS

A total of 200 consecutive treatment-naïve patients were enrolled. Baseline characteristics were similar between groups, with 15.5% of subjects reporting prior macrolide use. Eradication occurred in 78% (95% CI 68.6-85.7%) in both groups on intention-to-treat analysis. Per-protocol rates were 82.1 vs. 83.9% for standard-dose patients vs. half-dose patients, respectively (p = NS). Adverse events (only mild) were reported in 57 vs. 41% of standard-dose patients vs. half-dose patients (p = 0.024), with metallic taste and nausea notably less frequent in the latter (36 vs. 12% and 18 vs. 7%, respectively; p < 0.05 for both). Overall, eradication failed in 38.7% of prior macrolide users vs. 18.9% without such exposure (p = 0.019). On multivariate logistic regression, prior macrolide exposure was the only factor associated with failed eradication (OR 2.60, 95% CI 1.06-6.39; p = 0.038). Treatment was cheaper with the half-dose regimen.

INTERPRETATION

A 50% reduction in antibiotic dosage does not diminish efficacy of concomitant nonbismuth quadruple therapy but leads to significant reduction in cost and adverse events. Seven-day concomitant NBQT is suboptimal for H. pylori independent of prior macrolide exposure.

Treatment of Helicobacter pylori infection 2012

Helicobacter pylori resistance rates to antibiotics vary in different countries and even in different regions of the same country. Choice of treatment is strongly dependent on antibiotic resistance rates. In some countries, triple therapy with a proton-pump inhibitor, amoxicillin, and clarithromycin is still the best option, but eradication results fall short of what would be desired (90-95%) in countries with clarithromycin resistance >20%, bismuth-containing quadruple therapy, or nonbismuth sequential or concomitant therapies may then be the preferred option. Newer antibiotic regimens are awaited. Vaccination would be the best option, especially for developing countries, but little progress has been made in designing a vaccine.

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

BACKGROUND

Traditional standard triple therapy for Helicobacter pylori (H. pylori) infection (proton pump inhibitor-clarithromycin-amoxicillin) can easily be converted to non-bismuth quadruple (concomitant) therapy by the addition of a nitroimidazole twice daily.

AIM

To critically review evidence on the role of non-bismuth quadruple therapy (proton pump inhibitor-clarithromycin-amoxicillin-nitroimidazole) in the treatment of H. pylori infection.

METHODS

Bibliographical searches were performed in MEDLINE and relevant congresses up to December 2011. We performed a meta-analysis of the studies evaluating the concomitant therapy, and of the randomized controlled trials comparing the concomitant and the standard triple therapy.

RESULTS

A meta-analysis of 19 studies (2070 patients) revealed a mean H. pylori cure rate (intention-to-treat) of 88% (95% confidence interval from 85% to 91%) for non-bismuth quadruple therapy. We performed a meta-analysis of the randomized controlled studies comparing the concomitant (481 patients) and the standard triple therapy (503 patients). The former was more effective than the latter: 90% versus 78% (intention-to-treat analysis). Results were homogeneous (I(2) = 0%). The odds ratio for this comparison was 2.36 (95% confidence interval from 1.67 to 3.34). A tendency toward better results with longer treatments (7-10 days versus 3-5 days) has been observed, so it seems reasonable to recommend the length of treatment achieving the highest cure rates (10 days). Clarithromycin resistance may reduce the efficacy of non-bismuth quadruple therapy, although the decrease in eradication rates seems to be far lower than in standard triple therapy. Experience with the non-bismuth quadruple therapy in patients with metronidazole-resistant strains is still very limited.

CONCLUSION

Non-bismuth quadruple (concomitant) therapy appears to be an effective, safe, and well-tolerated alternative to triple therapy and is less complex than sequential therapy. Therefore, this regimen appears well suited for use in settings where the efficacy of triple therapy is unacceptably low.