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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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2
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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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3
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Singh SP, Ahuja V, Ghoshal UC, Makharia G, Dutta U, Zargar SA, Venkataraman J, Dutta AK, Mukhopadhyay AK, Singh A, Thapa BR, Vaiphei K, Sathiyasekaran M, Sahu MK, Rout N, Abraham P, Dalai PC, Rathi P, Sinha SK, Bhatia S, Patra S, Ghoshal U, Poddar U, Mouli VP, Kate V. Management of Helicobacter pylori infection: The Bhubaneswar Consensus Report of the Indian Society of Gastroenterology. Indian J Gastroenterol 2021; 40:420-444. [PMID: 34219211 DOI: 10.1007/s12664-021-01186-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/20/2021] [Indexed: 02/04/2023]
Abstract
The Indian Society of Gastroenterology (ISG) felt the need to organize a consensus on Helicobacter pylori (H. pylori) infection and to update the current management of H. pylori infection; hence, ISG constituted the ISG's Task Force on Helicobacter pylori. The Task Force on H. pylori undertook an exercise to produce consensus statements on H. pylori infection. Twenty-five experts from different parts of India, including gastroenterologists, pathologists, surgeons, epidemiologists, pediatricians, and microbiologists participated in the meeting. The participants were allocated to one of following sections for the meeting: Epidemiology of H. pylori infection in India and H. pylori associated conditions; diagnosis; treatment and retreatment; H. pylori and gastric cancer, and H. pylori prevention/public health. Each group reviewed all published literature on H. pylori infection with special reference to the Indian scenario and prepared appropriate statements on different aspects for voting and consensus development. This consensus, which was produced through a modified Delphi process including two rounds of face-to-face meetings, reflects our current understanding and recommendations for the diagnosis and management of H. pylori infection. These consensus should serve as a reference for not only guiding treatment of H. pylori infection but also to guide future research on the subject.
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Affiliation(s)
- Shivaram Prasad Singh
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, 753 007, India.
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Showkat Ali Zargar
- Department of Gastroenterology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, 190 011, India
| | - Jayanthi Venkataraman
- Department of Hepatology, Sri Ramachandra Medical Centre, No. 1 Ramachandra Nagar, Porur, Chennai, 600 116, India
| | - Amit Kumar Dutta
- Department of Gastrointestinal Sciences, Christian Medical College and Hospital, Vellore, 632 004, India
| | - Asish K Mukhopadhyay
- Division of Bacteriology, National Institute of Cholera and Enteric Diseases, Kolkata, 700 010, India
| | - Ayaskanta Singh
- Department of Gastroenterology, IMS and Sum Hospital, Bhubaneswar, 756 001, India
| | - Babu Ram Thapa
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Superspeciality of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Kim Vaiphei
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160 012, India
| | - Malathi Sathiyasekaran
- Department of Pediatric Gastroenterology, Kanchi Kamakoti Childs Trust Hospital, Chennai, 600 034, India
| | - Manoj K Sahu
- Department of Gastroenterology, IMS and Sum Hospital, Bhubaneswar, 756 001, India
| | - Niranjan Rout
- Department of Pathology, Acharya Harihar Post Graduate Institute of Cancer, Manglabag, Cuttack, 753 007, India
| | - Philip Abraham
- P D Hinduja Hospital and Medical Research Centre, Veer Savarkar Marg, Cadel Road, Mahim, Mumbai, 400 016, India
| | - Prakash Chandra Dalai
- Gastro and Kidney Care Hospital, IRC Village, Nayapalli, Bhubaneswar, 751 015, India
| | - Pravin Rathi
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Shobna Bhatia
- Department of Gastroenterology and Hepatobiliary Sciences, Sir HN Reliance Foundation Hospital and Research Centre, Raja Rammohan Roy Road, Prarthana Samaj, Girgaon, Mumbai, 400 004, India
| | - Susama Patra
- Department of Pathology, All India Institute of Medical Sciences, Patrapada, Bhubaneswar, 751 019, India
| | - Ujjala Ghoshal
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | | | - Vikram Kate
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605 006, India
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Gisbert JP. Rifabutin for the Treatment of Helicobacter Pylori Infection: A Review. Pathogens 2020; 10:pathogens10010015. [PMID: 33379336 PMCID: PMC7823349 DOI: 10.3390/pathogens10010015] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 12/17/2020] [Accepted: 12/24/2020] [Indexed: 12/12/2022] Open
Abstract
Nowadays, apart from having to know first-line Helicobacter pylori eradication regimens well, we must also be prepared to face treatment failures. The aim of this review is to summarize the role of rifabutin in the management of H. pylori infection. Bibliographical searches were performed in PubMed. Data on resistance and efficacy of rifabutin-containing regimens on H. pylori eradication were meta-analyzed. Mean H. pylori rifabutin resistance rate (39 studies, including 9721 patients) was 0.13%; when studies only including patients naïve to H. pylori eradication treatment were considered, this figure was even lower (0.07%). Mean H. pylori eradication rate (by intention-to-treat) with rifabutin-containing regimens (3052 patients) was 73%. Respective cure rates for second-, third-, fourth- and fifth-line therapies, were 79%, 69%, 69% and 72%. Most studies administered rifabutin 300 mg/day, which seemed to be more effective than 150 mg/day. The ideal length of treatment remains unclear, but 10–12-day regimens are generally recommended. Adverse events to rifabutin treatment in H. pylori studies were relatively infrequent (15%), and severe adverse events were exceptional (myelotoxicity was the most significant, although always reversible). In summary, rifabutin-containing therapy represents an encouraging strategy generally restricted, at present, to patients where previous (usually multiple) eradication regimens have failed.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), 28006 Madrid, Spain
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Gisbert JP. Optimization Strategies Aimed to Increase the Efficacy of Helicobacter pylori Eradication Therapies with Quinolones. Molecules 2020; 25:E5084. [PMID: 33147814 PMCID: PMC7663000 DOI: 10.3390/molecules25215084] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 10/28/2020] [Accepted: 10/31/2020] [Indexed: 12/14/2022] Open
Abstract
H. pylori infection is the main cause of gastritis, gastroduodenal ulcer disease, and gastric cancer. Fluoroquinolones such as levofloxacin, or more recently moxifloxacin or sitafloxacin, are efficacious alternatives to standard antibiotics for H. pylori eradication. The aim of the present review is to summarize the role of quinolone-based eradication therapies, mainly focusing on the optimization strategies aimed to increase their efficacy. Several meta-analyses have shown that, after failure of a first-line eradication treatment, a levofloxacin-containing rescue regimen is at least equally effective, and better tolerated, than the generally recommended bismuth quadruple regimen. Compliance with the levofloxacin regimens is excellent, and the safety profile is favourable. Higher cure rates have been reported with longer treatments (>10-14 days), and 500 mg levofloxacin daily is the recommended dose. Adding bismuth to the standard triple regimen (PPI-amoxicillin-levofloxacin) has been associated with encouraging results. Unfortunately, resistance to quinolones is easily acquired and is increasing in most countries, being associated with a decrease in the eradication rate of H. pylori. In summary, a quinolone (mainly levofloxacin)-containing regimen is an encouraging second-line (or even third-line) strategy, and a safe and simple alternative to bismuth quadruple therapy in patients whose previous H. pylori eradication therapy has failed.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), 28006 Madrid, Spain
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6
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Abstract
As one of the most prevalent infections globally, Helicobacter pylori (H. pylori) continues to present diagnostic and therapeutic challenges for clinicians worldwide. Diagnostically, the "test-and-treat" strategy is the recommended approach for healthcare practitioners when managing this potentially curable disease. The choice of testing method should be based on several factors including patient age, presenting symptoms, and medication use, as well as test reliability, availability, and cost. With rising antibiotic resistance, particularly of macrolides, care must be taken to ensure that therapy is selected based on regional resistance patterns and prior antibiotic exposure. In the USA, macrolide antibiotic resistance rates in some areas have reached or exceeded a generally accepted threshold, such that clarithromycin triple therapy may no longer be an appropriate first-line empiric treatment. Instead, bismuth quadruple therapy should be considered, while levofloxacin-based or alternative macrolide-containing therapies are also options. Once treated, it is essential to test for eradication as untreated H. pylori is associated with serious complications including peptic ulcer disease, mucosa-associated lymphoid tissue lymphoma, and gastric cancer. This review article aims to consolidate current knowledge of H. pylori infection with a particular emphasis on diagnostic and treatment strategies.
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Affiliation(s)
- Bernardo Guevara
- Department of Internal Medicine, University of California Davis School of Medicine, 4150 V Street, Suite 1100, Sacramento, CA, 95817, USA
| | - Asha Gupta Cogdill
- Division of Gastroenterology and Hepatology, UC Davis Medical Center, University of California Davis School of Medicine, 4150 V Street, Suite 3500, Sacramento, CA, 95817, USA.
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7
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Burgos‐Santamaría D, McNicholl AG, Gisbert JP. Empirical
Helicobacter pylori
rescue therapy: an 18‐year single‐centre study of 1200 patients. ACTA ACUST UNITED AC 2019. [DOI: 10.1002/ygh2.372] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Diego Burgos‐Santamaría
- Department of Gastroenterology and Hepatology Hospital Universitario Ramón y Cajal Instituto Ramón y Cajal De Investigación Sanitaria (IRYCIS) Universidad de Alcalá Madrid Spain
| | - Adrian G. McNicholl
- Gastroenterology Unit Hospital Universitario de La Princesa Instituto de Investigación Sanitaria Princesa (IIS‐IP) Universidad Autónoma de Madrid Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD) Madrid Spain
| | - Javier P. Gisbert
- Gastroenterology Unit Hospital Universitario de La Princesa Instituto de Investigación Sanitaria Princesa (IIS‐IP) Universidad Autónoma de Madrid Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD) Madrid Spain
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Current Status of the Third-Line Helicobacter pylori Eradication. Gastroenterol Res Pract 2018; 2018:6523653. [PMID: 29853863 PMCID: PMC5954858 DOI: 10.1155/2018/6523653] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/08/2018] [Indexed: 02/08/2023] Open
Abstract
Antibiotic resistance is growing worldwide, and patients who have failed consecutive 1st- and 2nd-line H. pylori eradication regimens are increasing. Therefore, the role of the bacterial culture with antibiotic susceptibility testing and molecular susceptibility testing is important for avoiding the use of ineffective antibiotics. However, antibiotic susceptibility testing-guided treatment does not necessarily guarantee successful eradication, and there have been mixed results for the effectiveness of a 3rd-line rescue therapy. Therefore, providing patients with pretreatment medication instructions and education is important. It is also crucial to determine the reason of the eradication failure, including host-related factors (poor compliance to eradication regimen, smoking, and cytochrome P450 2C19 genetic polymorphism) or treatment-related factors (inadequate dosage or duration of therapy and gastric acidity), as such factors can be modified for a tailored therapy. Although the indications for H. pylori eradication have widened, patients at a high risk of gastric cancer can gain definitive benefits with a 3rd-line or even 4th-line therapy.
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9
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Siddique O, Ovalle A, Siddique AS, Moss SF. Helicobacter pylori Infection: An Update for the Internist in the Age of Increasing Global Antibiotic Resistance. Am J Med 2018; 131:473-479. [PMID: 29353050 DOI: 10.1016/j.amjmed.2017.12.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 02/07/2023]
Abstract
Helicobacter pylori infects approximately half the world's population and is especially prevalent in the developing world. H. pylori is an important cause of global ill health due to its known etiological role in peptic ulcer disease, dyspepsia, gastric cancer, lymphoma, and more recently, recognized in iron deficiency anemia and idiopathic thrombocytopenic purpura. Increased antibiotic usage worldwide has led to antibiotic resistance among many bacteria, including H. pylori, resulting in falling success rates of first-line anti-H. pylori therapies. Eradication failures are principally due to resistance to clarithromycin, levofloxacin, and metronidazole. Several new treatment options or modifications of established regimens are now recommended by updated practice guidelines for primary or secondary therapy. Because these updated recommendations were published in the gastroenterological literature, internists and primary care physicians, who commonly manage H. pylori, may be unaware of these advances. In this review, we outline the changing epidemiology of H. pylori, advise on diagnostic test selection for patients not undergoing endoscopy, and highlight current management options in this era of growing antibacterial resistance.
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Affiliation(s)
- Osama Siddique
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI
| | - Anais Ovalle
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI
| | | | - Steven F Moss
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI; Division of Gastroenterology and Hepatology, Alpert Medical School of Brown University, Providence, RI.
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10
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Lim JH, Kim SG, Song JH, Hwang JJ, Lee DH, Han JP, Hong SJ, Kim JH, Jeon SW, Kim GH, Shim KN, Shin WG, Kim TH, Kim SM, Chung IK, Kim HS, Kim HU, Lee J, Kim JG. Efficacy of Levofloxacin-Based Third-Line Therapy for the Eradication of Helicobacter pylori in Peptic Ulcer Disease. Gut Liver 2017; 11:226-231. [PMID: 27609487 PMCID: PMC5347646 DOI: 10.5009/gnl16099] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 03/25/2016] [Accepted: 03/25/2016] [Indexed: 01/10/2023] Open
Abstract
Background/Aims The resistance rate of Helicobacter pylori is gradually increasing. We aimed to evaluate the efficacy of levofloxacin-based third-line H. pylori eradication in peptic ulcer disease. Methods Between 2002 and 2014, 110 patients in 14 medical centers received levofloxacin-based third-line H. pylori eradication therapy for peptic ulcer disease. Of these, 88 were included in the study; 21 were excluded because of lack of follow-up and one was excluded for poor compliance. Their eradication rates, treatment regimens and durations, and types of peptic ulcers were analyzed. Results The overall eradiation rate was 71.6%. The adherence rate was 80.0%. All except one received a proton-pump inhibitor, amoxicillin, and levofloxacin. One received a proton-pump inhibitor, amoxicillin, levofloxacin, and clarithromycin, and the eradication was successful. Thirty-one were administered the therapy for 7 days, 25 for 10 days, and 32 for 14 days. No significant differences were observed in the eradication rates between the three groups (7-days, 80.6% vs 10-days, 64.0% vs 14-days, 68.8%, p=0.353). Additionally, no differences were found in the eradiation rates according to the type of peptic ulcer (gastric ulcer, 73.2% vs duodenal/gastroduodenal ulcer, 68.8%, p=0.655). Conclusions Levofloxacin-based third-line H. pylori eradication showed efficacy similar to that of previously reported first/second-line therapies.
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Affiliation(s)
- Joo Hyun Lim
- Department of Internal Medicine, Seoul National University Hospital, Healthcare System Gangnam Center, Healthcare Research Institute, Seoul, Korea.,Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Hyun Song
- Department of Internal Medicine, Seoul National University Hospital, Healthcare System Gangnam Center, Healthcare Research Institute, Seoul, Korea
| | - Jae Jin Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dong Ho Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Pil Han
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Su Jin Hong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Ji Hyun Kim
- Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Seong Woo Jeon
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Woon Geon Shin
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Tae Ho Kim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Bucheon, Korea
| | - Sun Moon Kim
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Il-Kwon Chung
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hyun-Soo Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Heung Up Kim
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Joongyub Lee
- Medical Research Collaborating Center, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - Jae Gyu Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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Puig I, González-Santiago JM, Molina-Infante J, Barrio J, Herranz MT, Algaba A, Castro M, Gisbert JP, Calvet X. Fourteen-day high-dose esomeprazole, amoxicillin and metronidazole as third-line treatment for Helicobacter pylori infection. Int J Clin Pract 2017; 71. [PMID: 28869699 DOI: 10.1111/ijcp.13004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 08/09/2017] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION The efficacy of currently recommended third-line therapies for Helicobacter pylori is suboptimal, even that of culture-guided treatments. Resistance to multiple antibiotics is the major factor related to treatment failure. The aim of this study was to evaluate the effectiveness and safety of a 14-day therapy using high-dose of amoxicillin, metronidazole and esomeprazole. MATERIAL AND METHODS Multicenter open-label study as a register in routine clinical practice in patients with two previous failures of eradication therapy. A triple therapy with esomeprazole 40 mg b.d., amoxicillin 1 g t.d.s and metronidazole 500 mg t.d.s for 2 weeks was administered as a third-line therapy after a first treatment including clarithromycin and a second treatment including a quinolone. Helicobacter pylori status was determined by either histology or 13 C-UBT both before and after treatment. RESULTS A total of 68 patients were included in this study. An interim analysis showed that only three out of eight patients who had received metronidazole in previous eradication regimens were cured (37%, 95% CI 8-75); as a result, after this interim analysis only metronidazole-naïve patients were included. The ITT eradication rate in metronidazole-naive patients was 64% (95% CI 51-76). Adverse events occurred in 58% of patients, all of them mild-to-moderate. Two patients (3%) did not complete >90% of the treatment because of side effects. No severe adverse events occurred. CONCLUSION Cure rates of this 14-day schedule using high-dose esomeprazole, amoxicillin and metronidazole as a third-line eradication regimen were suboptimal, especially in patients who had received metronidazole in previous failed eradication regimens.
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Affiliation(s)
- Ignasi Puig
- Digestive Diseases Unit, Althaia Xarxa Assistencial Universitària de Manresa, Barcelona, Spain
- Universitat Internacional de Catalunya, Barcelona, Spain
| | - Jesús M González-Santiago
- Department of Gastroenterology, Hospital Clínico Universitario, Salamanca, Spain
- Biomedical Research Institute of Salamanca (IBSAL), Salamanca, Spain
| | | | - Jesús Barrio
- Department of Gastroenterology, Hospital Rio Hortega, Valladolid, Spain
| | | | - Alicia Algaba
- Department of Gastroenterology, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | - Manuel Castro
- Department of Gastroenterology, Hospital de Valme, Sevilla, Spain
- Centro de Investigación Biomédica en Red de enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Javier P Gisbert
- Centro de Investigación Biomédica en Red de enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Xavier Calvet
- Centro de Investigación Biomédica en Red de enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Digestive Diseases Unit, Corporació Sanitaria Universitària Parc Taulí, Sabadell, Spain
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12
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Fontes LES, Martimbianco ALC, Mochdece CC, Riera R. Proton pump inhibitor- and fluoroquinolone-based triple therapies for Helicobacter pylorieradication. Hippokratia 2017. [DOI: 10.1002/14651858.cd012588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Luís Eduardo S Fontes
- Petrópolis Medical School; Department of Evidence-Based Medicine, Intensive Care, Gastroenterology; Av Barao do Rio Branco, 1003 Petrópolis RJ Brazil 25680-120
| | - Ana Luiza C Martimbianco
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde; Cochrane Brazil; Rua Borges Lagoa, 564 cj 63 São Paulo SP Brazil 04038-000
| | | | - Rachel Riera
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde; Cochrane Brazil; Rua Borges Lagoa, 564 cj 63 São Paulo SP Brazil 04038-000
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13
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Sung J, Kim N, Park YH, Hwang YJ, Kwon S, Na G, Choi JY, Kang JB, Kim HR, Kim JW, Lee DH. Rifabutin-based Fourth and Fifth-line Rescue Therapy in Patients with forHelicobacter pyloriEradication Failure. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 69:109-118. [DOI: 10.4166/kjg.2017.69.2.109] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Jihee Sung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Nayoung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yo Han Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Jae Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Soohoon Kwon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Gyeongjae Na
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Joon Young Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Bin Kang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hye Rang Kim
- Hospital Health Promotion Center, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jin-Wook Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Ho Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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14
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Puig I, López-Góngora S, Calvet X, Villoria A, Baylina M, Sanchez-Delgado J, Suarez D, García-Hernando V, Gisbert JP. Systematic review: third-line susceptibility-guided treatment for Helicobacter pylori infection. Therap Adv Gastroenterol 2016; 9:437-48. [PMID: 27366212 PMCID: PMC4913327 DOI: 10.1177/1756283x15621229] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Susceptibility-guided therapies (SGTs) have been proposed as preferable to empirical rescue treatments after two treatment failures. The aim of this study was to perform a systematic review and meta-analysis evaluating the effectiveness and efficacy of SGT as third-line therapy. METHODS A systematic search was performed in multiple databases. Studies reporting cure rates of Helicobacter pylori with SGT in third-line therapy were selected. A qualitative analysis describing the current evidence and a pooled mean analysis summarizing the cure rates of SGT in third-line therapy was performed. RESULTS No randomized controlled trials or comparative studies were found. Four observational studies reported cure rates with SGT in third-line treatment, and three studies which mixed patients with second- and third-line treatment also reported cure rates with SGT. The majority of the studies included the patients when culture had been already obtained, and so the effectiveness of SGT and empirical therapy has never been compared. A pooled mean analysis including four observational studies (283 patients) showed intention-to-treat and per-protocol eradication rates with SGT of 72% (95% confidence interval 56-87%; I(2) : 92%) and 80% (95% confidence interval 71-90%; I(2) : 80%), respectively. CONCLUSIONS SGT may be an acceptable option as rescue treatment. However, cure rates are, at best, moderate and this approach has never been compared with a well-devised empirical therapy. The evidence in favor of SGT as rescue therapy is currently insufficient to recommend its use.
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Affiliation(s)
| | | | | | - Albert Villoria
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain,Digestive Diseases Unit, Corporació Sanitaria Universitària Parc Taulí, Sabadell, Spain,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - Mireia Baylina
- Internal Medicine Department, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
| | - Jordi Sanchez-Delgado
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain,Digestive Diseases Unit, Corporació Sanitaria Universitària Parc Taulí, Sabadell, Spain,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - David Suarez
- Unitat d’Epidemiologia i Avaluació, Hospital de Sabadell, Sabadell, Spain
| | | | - Javier P. Gisbert
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain,Servicio de Aparato Digestivo, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
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15
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Gisbert JP, Molina-Infante J, Amador J, Bermejo F, Bujanda L, Calvet X, Castro-Fernández M, Cuadrado-Lavín A, Elizalde JI, Gene E, Gomollón F, Lanas Á, Martín de Argila C, Mearin F, Montoro M, Pérez-Aisa Á, Pérez-Trallero E, McNicholl AG. IV Spanish Consensus Conference on Helicobacter pylori infection treatment. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:697-721. [PMID: 27342080 DOI: 10.1016/j.gastrohep.2016.05.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/18/2016] [Accepted: 05/19/2016] [Indexed: 02/06/2023]
Abstract
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.
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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), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| | | | - Javier Amador
- Medicina de Familia, Centro de Salud Los Ángeles, Madrid, España
| | - Fernando Bermejo
- Servicio de Aparato Digestivo, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - Luis Bujanda
- Servicio de 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
| | | | | | - J Ignasi Elizalde
- Servicio de Aparato Digestivo, Hospital Clínic, CIBEREHD, Barcelona, España
| | - Emili Gene
- Servicio de Urgencias, Hospital Parc Taulí Sabadell, CIBEREHD, Universitat Internacional de Catalunya, Sabadell, Barcelona, España
| | - Fernando Gomollón
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, España
| | - Ángel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, España
| | - Carlos Martín de Argila
- Servicio de Aparato Digestivo, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, España
| | - Fermín Mearin
- Servicio de Aparato Digestivo, Centro Médico Teknon, Barcelona, España
| | - Miguel Montoro
- Servicio de Aparato Digestivo, Hospital San Jorge, Huesca, España
| | - Ángeles Pérez-Aisa
- Servicio de Aparato Digestivo, Agencia Sanitaria Costa del Sol, Marbella, Málaga, España
| | - Emilio Pérez-Trallero
- Servicio de Microbiología, Hospital Donostia/Instituto Biodonostia, Universidad del País Vasco UPV/EHU, CIBEREHD, San Sebastián, España
| | - Adrián G McNicholl
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España
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16
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Noh HM, Hong SJ, Han JP, Park KW, Lee YN, Lee TH, Ko BM, Lee JS, Lee MS. Eradication Rate by Duration of Third-line Rescue Therapy with Levofloxacin afterHelicobacter pyloriTreatment Failure in Clinical Practice. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2016; 68:260-264. [DOI: 10.4166/kjg.2016.68.5.260] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Hyung Min Noh
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
- Digestive Disease Center and Research Institute, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Su Jin Hong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
- Digestive Disease Center and Research Institute, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jae Pil Han
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
- Digestive Disease Center and Research Institute, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
- Digestive Disease Center and Research Institute, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Yun Nah Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
- Digestive Disease Center and Research Institute, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Tae Hee Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
- Digestive Disease Center and Research Institute, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Bong Min Ko
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
- Digestive Disease Center and Research Institute, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Joon Seong Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
- Digestive Disease Center and Research Institute, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Moon Sung Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
- Digestive Disease Center and Research Institute, Soonchunhyang University College of Medicine, Bucheon, Korea
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17
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Ierardi E, Losurdo G, Giorgio F, Iannone A, Principi M, Leo AD. Quinolone-based first, second and third-line therapies for Helicobacter pylori. World J Pharmacol 2015; 4:274-280. [DOI: 10.5497/wjp.v4.i4.274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/08/2015] [Accepted: 11/17/2015] [Indexed: 02/07/2023] Open
Abstract
Helicobacter pylori (H. pylori) is a very common bacterium that infects about 50% of the world population in urban areas and over 90% of people living in rural and developing countries. Fluoroquinolones, a class of antimicrobials, have been extensively used in eradication regimens for H. pylori. Levofloxacin is the most commonly used, and in second-line regimens, is one of the most effective options. However, an increasing resistance rate of H. pylori to fluoroquinolones is being observed, that will likely affect their effectiveness in the near future. Other novel fluoroquinolone molecules, such as moxifloxacin, sitafloxacin, gatifloxacin and gemifloxacin, have been proposed and showed encouraging results in vitro, although data on their clinical use are still limited. Further studies in large sample trials are needed to confirm their safety and efficacy profile in clinical practice.
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18
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López-Góngora S, Puig I, Calvet X, Villoria A, Baylina M, Muñoz N, Sanchez-Delgado J, Suarez D, García-Hernando V, Gisbert JP. Systematic review and meta-analysis: susceptibility-guided versus empirical antibiotic treatment for Helicobacter pylori infection. J Antimicrob Chemother 2015; 70:2447-55. [PMID: 26078393 DOI: 10.1093/jac/dkv155] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 05/16/2015] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The cure rate of standard triple therapy for Helicobacter pylori infection is unacceptably low. Susceptibility-guided therapies (SGTs) have been proposed as an alternative to standard empirical treatments. The aim of this study was to perform a systematic review and meta-analysis evaluating the efficacy of SGTs. METHODS A systematic search was performed in multiple databases. Randomized controlled trials comparing cure rates of SGTs versus those of empirical therapy were selected and analysed separately for first- and second-line treatments. A meta-analysis was performed using risk ratio (RR) and number needed to treat (NNT) to measure the effect. RESULTS Twelve studies were included in the meta-analysis. In first-line treatment, SGT was more efficacious than empirical 7-10 day triple therapy (RR 1.16, 95% CI 1.10-1.23, I (2) = 33%; NNT = 8). Most studies used a 7-10 day triple therapy and randomized the patients after endoscopy and/or culture, thus precluding the comparison of SGT versus non-invasive testing and empirical treatment in clinical practice. For second-line therapy, only four studies were found. Results were highly heterogeneous and no significant differences were found (RR 1.11, 95% CI 0.82-1.51, I (2) = 87%). CONCLUSIONS Once endoscopy and culture have been performed, SGT is superior to empirical 7 or 10 day triple therapy for first-line treatment. Further studies are needed to evaluate the effectiveness of SGT in clinical practice, especially when compared with currently recommended first-line quadruple therapies.
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Affiliation(s)
- Sheila López-Góngora
- Internal Medicine Department, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
| | - Ignasi Puig
- Digestive Diseases Unit, Althaia Xarxa Assistencial, Universitaria de Manresa, Barcelona, Spain Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain Departament de Medicina, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Xavier Calvet
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain Digestive Diseases Unit, Corporació Sanitaria Universitària Parc Taulí, Sabadell, Spain Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - Albert Villoria
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain Digestive Diseases Unit, Corporació Sanitaria Universitària Parc Taulí, Sabadell, Spain Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - Mireia Baylina
- Internal Medicine Department, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
| | - Neus Muñoz
- Internal Medicine Department, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
| | - Jordi Sanchez-Delgado
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain Digestive Diseases Unit, Corporació Sanitaria Universitària Parc Taulí, Sabadell, Spain Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - David Suarez
- Unitat d'Epidemiologia i Avaluació, Hospital de Sabadell, Sabadell, Spain
| | - Victor García-Hernando
- Internal Medicine Department, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
| | - Javier P Gisbert
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain Servicio de Aparato Digestivo, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
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19
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Kim JH. Recent Update on Third-lineHelicobacter pyloriEradication. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2015. [DOI: 10.7704/kjhugr.2015.15.2.89] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Ji Hyun Kim
- Department of Gastroenterology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
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20
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Keshavarz Azizi Raftar S, Moniri R, Saffari M, Zadeh MR, Arj A, Abbas Moosavi SG, Ghazi Kalayeh HM. Helicobacter pylori resistance to ciprofloxacin in Iran. Int J Antimicrob Agents 2014; 43:573-4. [DOI: 10.1016/j.ijantimicag.2014.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 03/11/2014] [Accepted: 03/12/2014] [Indexed: 01/10/2023]
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21
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Furuta T, Sugimoto M, Kodaira C, Nishino M, Yamade M, Uotani T, Sahara S, Ichikawa H, Yamada T, Osawa S, Sugimoto K, Watanabe H, Umemura K. Sitafloxacin-based third-line rescue regimens for Helicobacter pylori infection in Japan. J Gastroenterol Hepatol 2014; 29:487-93. [PMID: 24224808 DOI: 10.1111/jgh.12442] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUNDS Quinolone-based regimens have been used as the rescue for eradication of Helicobacter pylori. Sitafloxacin is known to have low minimum inhibitory concentration for H. pylori. Here, we compared two sitafloxacin-based eradication regimens as rescue for the eradication of H. pylori. METHODS We attempted to eradicate H. pylori in 180 Japanese patients who had never failed in eradication of H. pylori with the triple proton pump inhibitor/amoxicillin/clarithromycin therapy (1st line) and the triple proton pump inhibitor/amoxicillin/metronidazole therapy (2nd line). They were assigned to either the triple therapy with rabeprazole 10 mg b.i.d./q.i.d., amoxicillin 500 mg q.i.d, and sitafloxacin 100 mg b.i.d. (RAS) for 1 or 2 weeks or the triple therapy with rabeprazole 10 mg b.i.d./q.i.d., metronidazole 250 mg b.i.d., and sitafloxacin 100 mg b.i.d. (RMS) for 1 or 2 weeks. Eradication was assessed via the (13) C-urea breath test and rapid urease test. RESULTS Intention-to-treat and per-protocol analyses of eradication rates were 84.1% (37/44) and 86.4% (37/43) with RAS for 1 week, 88.9% (40/45) and 90.9% (40/44) for RAS for 2 weeks, 90.9% (40/44) and 90.9% (40/44) for 1 week-RMS and 87.2% (41/47) and 91.1% (41/45) with RMS for 2 weeks. We noted no statistical significant differences in eradication rates among four regimens. CONCLUSION All of the above-described rescue regimens proved relatively equally useful in the eradication of H. pylori. Of them, RAS for 2 weeks and RMS for 1 or 2 weeks could attain the rescue eradication rates higher than 90% by per-protocol analysis.
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Affiliation(s)
- Takahisa Furuta
- Center for Clinical Research, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Gisbert JP. [Helicobacter pylori-related diseases]. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 35 Suppl 1:12-25. [PMID: 23018004 DOI: 10.1016/s0210-5705(12)70030-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This article summarizes the main conclusions drawn from the studies presented in Digestive Disease Week in 2012 on Helicobacter pylori infection. In developed countries, the prevalence of this infection has decreased, although it continues to be high. The prevalence in Spain is high (50%) and does not seem to be decreasing. There is an increase in antibiotic resistance, which is correlated with the frequency of prior antibiotic prescription. H. pylori eradication improves the symptoms of "epigastric pain syndrome" in functional dyspepsia. The frequency of idiopathic peptic ulcers seems to be increasing. To prevent the development of gastric cancer, eradication therapy should be administered early (before intestinal metaplasia develops). H. pylori eradication in patients undergoing early endoscopic resection of gastric cancer reduces the incidence of metachronous tumors, although endoscopic follow-up should be performed periodically. H. pylori eradication induces MALT lymphoma regression in most patients and tumoral recurrence in the long term is exceptional; radiotherapy is an excellent second-line option; a watch and wait approach to histologic recurrence after initial MALT lymphoma remission is a reasonable alternative. Idiopathic thrombocytopenic purpura is an indication for eradication therapy in children as well as adults. There are several diagnostic innovations, such as high-resolution endoscopy, narrow-band imaging, a method based on the electrochemical properties of H. pylori, and the cytosponge. Quadruple therapy with bismuth is at least as effective as standard triple therapy. The superiority of "sequential" therapy over standard triple therapy should be confirmed in distinct settings. The efficacy of "concomitant" therapy is similar -or even better- than that of "sequential" therapy, but has the advantage of being simpler. A hybrid sequential-concomitant therapy is highly effective. In patients allergic to beta-lactams, the efficacy of treatment with a proton pump inhibitor-clarithromycin-metronidazole is insufficient. When standard triple therapy fails, the second-line option of a 10-day course of levofloxacin is effective and is simpler and better tolerated than quadruple therapy. Triple therapy with levofloxacin is also a promising alternative after failure of "sequential" and "concomitant" therapy. New-generation quinolones, such as moxifloxacin and sitafloxacin, could be useful as eradication therapy, especially as rescue therapy. When two eradication therapies have failed, empirical administration of a third (e.g. levofloxacin) is a valid option. Even after three eradication therapies have failed, an empirical rescue therapy (with rifabutin) can be effective. H. pylori reinfection is highly frequent in developing countries, probably due to intrafamilial transmission.
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Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain.
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Murakami K, Furuta T, Ando T, Nakajima T, Inui Y, Oshima T, Tomita T, Mabe K, Sasaki M, Suganuma T, Nomura H, Satoh K, Hori S, Inoue S, Tomokane T, Kudo M, Inaba T, Take S, Ohkusa T, Yamamoto S, Mizuno S, Kamoshida T, Amagai K, Iwamoto J, Miwa J, Kodama M, Okimoto T, Kato M, Asaka M. Multi-center randomized controlled study to establish the standard third-line regimen for Helicobacter pylori eradication in Japan. J Gastroenterol 2013; 48:1128-35. [PMID: 23307042 DOI: 10.1007/s00535-012-0731-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 12/04/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUNDS The present study sought to establish a standard third-line eradication regimen for Helicobacter pylori in Japan. METHODS Subjects were 204 patients with H. pylori infection in whom the standard Japanese first- and second-line eradication therapies had proven unsuccessful. Patients were randomly assigned to one of the following third-line eradication therapy groups: (1) LA group: lansoprazole (LPZ) 30 mg 4 times a day (qid) + amoxicillin (AMPC) 500 mg qid for two weeks; (2) LAL group: LPZ 30 mg twice a day (bid) + AMPC 750 mg bid + levofloxacin (LVFX) 300 mg bid for one week; (3) LAS group: LPZ 30 mg bid + AMPC 750 mg bid + sitafloxacin (STFX) 100 mg bid for one week. Patients for whom these therapies failed underwent a crossover fourth-line eradication regimen. Drug sensitivity was also tested for AMPC, clarithromycin (CAM), MNZ, LVFX, and STFX. RESULTS Drug resistance rates prior to third-line eradication therapy were 86.4 % for CAM, 71.3 % for MNZ, 57.0 % for LVFX, 8.2 % for AMPC, and 7.7 % for STFX. Intention-to-treat analysis of third-line eradication therapy eradication rates showed a significantly higher rate in the LAS group (70.0 %) compared with the LA group (54.3 %; p < 0.05) and the LAL group (43.1 %; p < 0.001). The significantly lower rate in the LAL group than the LAS group was caused by bacterial resistance to LVFX. CONCLUSIONS The findings suggest that triple therapy with PPI, AMPC, and STFX for one week would be an effective standard third-line eradication regimen for H. pylori in Japan.
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Affiliation(s)
- Kazunari Murakami
- Department of Gastroenterology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yuhu, Oita, 879-5593, Japan,
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Calhan T, Kahraman R, Sahin A, Senates E, Doganay HL, Kanat E, Ozdil K, Sokmen HM. Efficacy of two levofloxacin-containing second-line therapies for Helicobacter pylori: a pilot study. Helicobacter 2013; 18:378-83. [PMID: 23601026 DOI: 10.1111/hel.12056] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND An ideal second-line therapeutic regimen for the treatment of patients who do not respond to standard triple therapy is currently being investigated. In this study, we aimed to investigate the efficacy of two levofloxacin-containing second-line therapies for Helicobacter pylori (H. pylori). MATERIALS AND METHODS One hundred and forty eight consecutive H. pylori -positive patients who did not respond to the standard triple therapy (77 female, 71 male) were enrolled in the study. The patients were randomized consecutively to two-second-line therapy groups; 73 to the levofloxacin-containing sequential (LCS) and 75 to the levofloxacin-containing quadruple (LCQ) therapy group. The LCS therapy group received pantoprazole 40 mg and amoxicillin 1,000 mg twice daily for 5 days followed by pantoprazole 40 mg twice daily and metronidazole 500 mg three times daily and levofloxacin 500 mg one time daily for 7 days. The LCQ therapy group received pantoprazole 40 mg twice daily, tetracycline 500 mg four times daily, bismuth subcitrate 300 mg four times daily and levofloxacin 500 mg one time daily for 10 days. H. pylori eradication was confirmed by stool antigen testing at least 6 weeks after cessation of therapy. Side-effects and compliance were assessed by a questionnaire. RESULTS Intention-to-treat cure rates were: 82.2% (95%CI; 73-91) and 90.6% (95%CI; 79-95) in the LCS and LCQ therapy, respectively. Per protocol cure rates were: 85.7% (95%CI; 75-92) and 93.1% (95%CI; 85-98) in the LCS and LCQ therapy, respectively. No statistically significant difference was found between two groups (p = .1). No differences in compliance or adverse effects were demonstrated between two groups. CONCLUSIONS This prospective trial demonstrates that both levofloxacin-containing sequential therapy and levofloxacin-containing quadruple therapy regimens have higher H. pylori eradication rates and are well tolerated. The levofloxacin-containing quadruple therapy is likely the best treatment option for a second-line therapy, at least in the Turkish population.
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Affiliation(s)
- Turan Calhan
- Department of Gastroenterology, Umraniye Training and Research Hospital, Istanbul, Turkey
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Gisbert JP, Calvet X, Bermejo F, Boixeda D, Bory F, Bujanda L, Castro-Fernández M, Dominguez-Muñoz E, Elizalde JI, Forné M, Gené E, Gomollón F, Lanas Á, Martín de Argila C, McNicholl AG, Mearin F, Molina-Infante J, Montoro M, Pajares JM, Pérez-Aisa A, Pérez-Trallero E, Sánchez-Delgado J. [III Spanish Consensus Conference on Helicobacter pylori infection]. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:340-74. [PMID: 23601856 DOI: 10.1016/j.gastrohep.2013.01.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 01/31/2013] [Indexed: 01/06/2023]
Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
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Gisbert JP, Calvet X, Ferrándiz J, Mascort J, Alonso-Coello P, Marzo M. [Clinical practice guideline on the management of patients with dyspepsia. Update 2012]. Aten Primaria 2012; 44:727.e1-727.e38. [PMID: 23036729 PMCID: PMC7025630 DOI: 10.1016/j.aprim.2012.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 05/30/2012] [Indexed: 12/13/2022] Open
Abstract
The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources. This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).
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Affiliation(s)
- Javier P. Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, España
| | - Xavier Calvet
- Corporació Universitària Parc Taulí, Departament de Medicina, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, España
| | - Juan Ferrándiz
- Subdireccion de Calidad, Dirección General de Atención al Paciente, Servicio Madrileño de Salud, Madrid, España
| | - Juan Mascort
- CAP Florida Sud, Institut Català de la Salut, Departament de Ciències Clíniques, Campus Bellvitge, Facultat de Medicina, Universitat de Barcelona, L’Hospitalet de Llobregat, Barcelona, España
| | - Pablo Alonso-Coello
- Centro Cochrane Iberoamericano, Instituto de Investigaciones Biomédicas (IIB Sant Pau) Barcelona, España
| | - Mercè Marzo
- Unitat de suport a la recerca – IDIAP Jordi Gol, Direcció d’Atenció Primària Costa De Ponent, Institut Català de la Salut, Barcelona, España
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[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012. [PMID: 23186826 DOI: 10.1016/j.gastrohep.2012.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources.This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).
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Jeong MH, Chung JW, Lee SJ, Ha M, Jeong SH, Na S, Na BS, Park SK, Kim YJ, Kwon KA, Ko KI, Jo Y, Hahm KB, Jung HY. [Comparison of rifabutin- and levofloxacin-based third-line rescue therapies for Helicobacter pylori]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2012; 59:401-6. [PMID: 22735872 DOI: 10.4166/kjg.2012.59.6.401] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIMS There is increasing need for third-line therapy of Helicobacter pylori due to increasing level of antibiotics resistance. The aim of this study was to compare rifabutin and levofloxacin rescue regimens in patients with first- and second-line Helicobacter pylori eradication failures. METHODS Patients, in whom a first treatment with proton pump inhibitor-clarithromycin-amoxicillin and a second trial with proton pump inhibitor-bismuth-tetracycline-metronidazole had failed, received treatment with either rifabutin or levofloxacin, plus amoxicillin (1 g twice daily) and standard dose proton pump inhibitor. Eradication rates were confirmed with 13C-urea breath test or rapid urease test 4 weeks after the cessation of therapy. RESULTS Eradication rates were 71.4% in the rifabutin group, and 57.1% in the levofloxacin group, respectively. Although there was no significant difference in Helicobacter pylori eradication rates between two groups (p=0.656), rifabutin based regimen showed relatively higher eradication rate. CONCLUSIONS Helicobacter pylori eradication rates of rifabutin- or levofloxacin-based triple therapy could not achieve enough eradication rate. Further studies would be needed on combination of levofloxacin and rifabutin-based regimen or culture based treatment.
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Affiliation(s)
- Myung Ho Jeong
- Department of Gastroenterology, Gachon Graduate School of Medicine, Gil Hospital, 1198, Namdong-gu, Incheon 405-760, Korea
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D'Elios MM, Silvestri E, Emmi G, Barnini T, Prisco D. Helicobacter pylori: usefulness of an empirical fourth-line rifabutin-based regimen. Expert Rev Gastroenterol Hepatol 2012; 6:437-9. [PMID: 22928895 DOI: 10.1586/egh.12.32] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Helicobacter pylori represents the major cause of gastric cancer, gastric lymphoma and peptic ulcer diseases. In some cases, the infection persists even after three rounds of treatment. The evaluated article reports on the efficacy of an empirical multicenter, prospective fourth‑line rescue study with rifabutin in patients with three consecutive eradication failures. A total of 100 patients (31% peptic ulcer and 69% functional dyspepsia) were included to receive a fourth‑line with rifabutin (150 mg twice daily [b.i.d.]), amoxicillin (1 g b.i.d.) and a proton‑pump inhibitor (standard dose b.i.d.) for 10 days. The end point was H. pylori eradication, determined by (13)C-urea breath test 4-8 weeks after therapy. H. pylori eradication was achieved in approximately 50% of patients. Adverse events (mainly metallic taste, nausea and diarrhea) were reported in 30 patients. Thus, a fourth-line rifabutin-based rescue therapy constitutes a valid strategy after multiple previous H. pylori eradication failures with key antibiotics, such as clarithromycin, metronidazole, tetracycline and levofloxacin.
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Nishizawa T, Suzuki H, Maekawa T, Harada N, Toyokawa T, Kuwai T, Ohara M, Suzuki T, Kawanishi M, Noguchi K, Yoshio T, Katsushima S, Tsuruta H, Masuda E, Tanaka M, Katayama S, Kawamura N, Nishizawa Y, Hibi T, Takahashi M. Dual therapy for third-line Helicobacter pylori eradication and urea breath test prediction. World J Gastroenterol 2012; 18:2735-8. [PMID: 22690086 PMCID: PMC3370014 DOI: 10.3748/wjg.v18.i21.2735] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 02/28/2012] [Accepted: 03/29/2012] [Indexed: 02/06/2023] Open
Abstract
We evaluated the efficacy and tolerability of a dual therapy with rabeprazole and amoxicillin (AMX) as an empiric third-line rescue therapy. In patients with failure of first-line treatment with a proton pump inhibitor (PPI)-AMX-clarithromycin regimen and second-line treatment with the PPI-AMX-metronidazole regimen, a third-line eradication regimen with rabeprazole (10 mg q.i.d.) and AMX (500 mg q.i.d.) was prescribed for 2 wk. Eradication was confirmed by the results of the 13C-urea breath test (UBT) at 12 wk after the therapy. A total of 46 patients were included; however, two were lost to follow-up. The eradication rates as determined by per-protocol and intention-to-treat analyses were 65.9% and 63.0%, respectively. The pretreatment UBT results in the subjects showing eradication failure; those patients showing successful eradication comprised 32.9 ± 28.8 permil and 14.8 ± 12.8 permil, respectively. The pretreatment UBT results in the subjects with eradication failure were significantly higher than those in the patients with successful eradication (P = 0.019). A low pretreatment UBT result (≤ 28.5 permil) predicted the success of the eradication therapy with a positive predictive value of 81.3% and a sensitivity of 89.7%. Adverse effects were reported in 18.2% of the patients, mainly diarrhea and stomatitis. Dual therapy with rabeprazole and AMX appears to serve as a potential empirical third-line strategy for patients with low values on pretreatment UBT.
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Gisbert JP. Letter: third-line rescue therapy with levofloxacin after failure of two treatments to eradicate Helicobacter pylori infection. Aliment Pharmacol Ther 2012; 35:1484-5; author reply 1486. [PMID: 22582841 DOI: 10.1111/j.1365-2036.2012.05117.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Efficacy of a "Rescue" Ciprofloxacin-Based Regimen for Eradication of Helicobacter pylori Infection after Treatment Failures. Gastroenterol Res Pract 2012; 2012:484591. [PMID: 22666234 PMCID: PMC3359787 DOI: 10.1155/2012/484591] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 03/10/2012] [Indexed: 02/07/2023] Open
Abstract
The aim of our study was to evaluate the efficacy and tolerability of a ciprofloxacin-based regimen for H. pylori eradication failures as an alternative to bismuth based quadruple therapy. Methods. Design: prospective single-center study. Patients in whom a first eradication trial with omeprazole/esomeprazole, clarithromycin plus amoxicillin or tinidazole/metronidazole had failed were included. H. pylori status: established by histology, rapide urease test and polymerase chain reaction. Intervention: esomeprazole 20 mg, ciprofloxacin 500 mg, and metronidazole 500 mg, administered together before breakfast and dinner for 10 days. Susceptibility testing was performed by the Epsilometer test. Ciprofloxacin resistance was defined as a MIC of ≥1 μg/mL. Eradication was established by a negative 13C-UBT and 4–6 weeks post-therapy. Efficacy and side effects were determined. Results. 34 patients were enrolled, 32 completed the study. Compliance was excellent (100%). Side effects were mild. Ciprofloxacin-based therapy cured 65% (22/34) of patients by intention to treat and 69% (22/32) per protocol analysis. The prevalence of ciprofloxacin resistance was 8%. Conclusions. The effectiveness of ciprofloxacin-based therapy was greatly reduced despite the high prevalence of ciprofloxacin sensitive H. pylori strains. Bismuth based quadruple therapy still remain the best choice as a “rescue” regimen in our region.
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Goh KL, Manikam J, Qua CS. High-dose rabeprazole-amoxicillin dual therapy and rabeprazole triple therapy with amoxicillin and levofloxacin for 2 weeks as first and second line rescue therapies for Helicobacter pylori treatment failures. Aliment Pharmacol Ther 2012; 35:1097-102. [PMID: 22404486 DOI: 10.1111/j.1365-2036.2012.05054.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2011] [Revised: 01/25/2012] [Accepted: 02/20/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND H. pylori eradication failures are difficult to treat and rescue therapies often consist of complex treatment regimens. AIM To determine an effective and practical rescue therapeutic strategy for H. pylori treatment failures using two consecutive regimens: first rescue therapy - rabeprazole 20 mg t.d.s. and amoxicillin 1 g t.d.s. for 2 weeks and for failures a further second rescue therapy - rabeprazole 20 mg b.d., levofloxacin 500 mg b.d., amoxicillin 1 g b.d. for a further 2 weeks. METHODS Consecutive patients who failed the proton pump inhibitor (PPI) 1-week triple therapy were recruited for the study. H. pylori status was determined by a C(13) urea breath test. RESULTS One hundred and forty-nine patients received the first rescue therapy. Seven were not compliant to medication/defaulted follow-up. Eradication success- first rescue therapy: per protocol (PP) analysis-107/142 (75.4%) (95% CI (68.3-82.4%) and intention to treat (ITT) analysis-107/149 (71.8%) 95% CI (64.6-79.0%). Thirty-one of 35 patients who failed the first rescue therapy received the second rescue therapy. All were compliant with medications. Eradication success- PP and ITT was 28/31 (90.3%) 95% CI (74.2-98.0%). The cumulative eradication rate using both rescue therapies: PP analysis- 135/138 (97.8%) 95% CI: (93.8-99.6%), ITT analysis- 135/149 (90.6%) 95% CI: (84.7-94.8%). CONCLUSIONS A 2-week high dose PPI-amoxicillin dual therapy followed by a PPI-amoxicillin-levofloxacin triple therapy were highly successful in achieving eradication in H. pylori treatment failures.
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Affiliation(s)
- K-L Goh
- Division of Gastroenterology and Hepatology, University of Malaya, Kuala Lumpur, Malaysia
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Gisbert JP, Castro-Fernandez M, Perez-Aisa A, Cosme A, Molina-Infante J, Rodrigo L, Modolell I, Cabriada JL, Gisbert JL, Lamas E, Marcos E, Calvet X. Fourth-line rescue therapy with rifabutin in patients with three Helicobacter pylori eradication failures. Aliment Pharmacol Ther 2012; 35:941-7. [PMID: 22372560 DOI: 10.1111/j.1365-2036.2012.05053.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 02/10/2012] [Accepted: 02/13/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND In some cases, Helicobacter pylori infection persists even after three eradication treatments. AIM To evaluate the efficacy of an empirical fourth-line rescue regimen with rifabutin in patients with three eradication failures. DESIGN Multicentre, prospective study. PATIENTS In whom the following three treatments had consecutively failed: first (PPI + clarithromycin + amoxicillin); second (PPI + bismuth + tetracycline + metronidazole); third (PPI + amoxicillin + levofloxacin). INTERVENTION A fourth regimen with rifabutin (150 mg b.d.), amoxicillin (1 g b.d.) and a PPI (standard dose b.d.) was prescribed for 10 days. OUTCOME Eradication was confirmed by (13) C-urea breath test 4-8 weeks after therapy. Compliance and tolerance: Compliance was determined through questioning and recovery of empty medication envelopes. Adverse effects were evaluated using a questionnaire. RESULTS One-hundred patients (mean age 50 years, 39% men, 31% peptic ulcer/69% functional dyspepsia) were included. Eight patients did not take the medication correctly (in six cases due to adverse effects). Per-protocol and intention-to-treat eradication rates were 52% (95% CI = 41-63%) and 50% (40-60%). Adverse effects were reported in 30 (30%) patients: nausea/vomiting (13 patients), asthenia/anorexia (8), abdominal pain (7), diarrhoea (5), fever (4), metallic taste (4), myalgia (4), hypertransaminasemia (2), leucopenia (<1,500 neutrophils) (2), thrombopenia (<150,000 platelets) (2), headache (1) and aphthous stomatitis (1). Myelotoxicity resolved spontaneously in all cases. CONCLUSIONS Even after three previous H. pylori eradication failures, an empirical fourth-line rescue treatment with rifabutin may be effective in approximately 50% of the cases. Therefore, rifabutin-based rescue therapy constitutes a valid strategy after multiple previous eradication failures with key antibiotics, such as clarithromycin, metronidazole, tetracycline and levofloxacin.
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Affiliation(s)
- J P Gisbert
- Gastroenterology Department, Hospital de La Princesa, Madrid, Spain.
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Gisbert JP, Calvet X. Update on non-bismuth quadruple (concomitant) therapy for eradication of Helicobacter pylori. Clin Exp Gastroenterol 2012; 5:23-34. [PMID: 22457599 PMCID: PMC3308633 DOI: 10.2147/ceg.s25419] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Javier P Gisbert
- Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IP), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Xavier Calvet
- Department of Gastroenterology, Hospital de Sabadell, Departament de Medicina, Universitat Autònoma de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
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Gisbert JP. [Helicobacter pylori-related diseases: dyspepsia, ulcers and gastric cancer]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 34 Suppl 2:15-26. [PMID: 22330153 DOI: 10.1016/s0210-5705(11)70017-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This article summarizes the main conclusions drawn from the presentations on Helicobacter pylori infection at Digestive Disease Week 2011. In developed countries, the prevalence of H. pylori infection has decreased, but seems to have reached a plateau at a fairly high level. Antibiotic resistance is increasing in several countries. H. pylori eradication does not contribute to the development of gastroesophageal reflux disease or worsen its course. The frequency of idiopathic peptic ulcers seems to be increasing. H. pylori eradication eliminates almost all episodes of peptic ulcer rebleeding; nevertheless, the use of non-steroidal anti-inflammatory drugs or H. pylori reinfection can lead to bleeding recurrence. H. pylori-negative patients with peptic ulcer bleeding more frequently have bleeding recurrences and higher mortality. In each particular population, there is a close correlation between the prevalence of H. pylori infection and the incidence of gastric cancer. H. pylori eradication is associated with a higher and faster healing rate of ulcerous lesions caused by endoscopic submucosal dissection. In patients undergoing endoscopic submucosal dissection for early gastric cancer, H. pylori eradication decreases the incidence of metachronous tumors. In a high proportion of cases, H. pylori eradication induces MALT lymphoma regression, and long-term tumoral recurrences are exceptional. Narrow-band imaging allows visualization of the mucous and vascular pattern in H. pylori-infected patients during the endoscopic examination. The electrochemical properties of H. pylori allow these lesions to be rapidly and accurately detected in gastric biopsies. The efficacy of "traditional" triple therapies currently leaves much to be desired. The superiority of "sequential" therapy over the standard triple therapy should be confirmed in distinct environments. The "concomitant" quadruple therapy seems to be as effective as "sequential" therapy, but with the advantage of being simpler. Both the "sequential" and the "concomitant" regimens are relatively effective even when clarithromycin resistance is present. Second-line rescue therapy with levofloxacin for 10 days is effective and is simpler and better tolerated than quadruple therapy. In patients allergic to penicillin, a combination with levofloxacin and clarithromycin is a promising rescue alternative. The new-generation quinolones, such as moxifloxacin and sitafloxacin, could be useful as eradication treatment. After two eradication treatment failures, an empirical third-line rescue therapy may be a valid option in clinical practice. Even after three previous H. pylori eradication failures, an empirical fourth-line rescue treatment with rifabutin may be effective.
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Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, España.
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Variability in Prevalence ofHelicobacter pyloriStrains Resistant to Clarithromycin and Levofloxacin in Southern Poland. Gastroenterol Res Pract 2012; 2012:418010. [PMID: 22693490 PMCID: PMC3368181 DOI: 10.1155/2012/418010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 03/15/2012] [Accepted: 03/29/2012] [Indexed: 02/07/2023] Open
Abstract
Background. An increasing resistance ofHelicobacter pyloristrains to antimicrobial agents is the serious therapeutic problem. The aim of this study was to compare the primary and secondary resistance ofH. pyloristrains isolated between 2006–2008 (data published) and 2009–2011 to clarithromycin and levofloxacin.Material and Methods. 220 dyspeptic patients (153 before treatment, 67 after), were enrolled in the study. 51H. pyloristrains were isolated. MIC values of clarithromycin and levofloxacin were determined by theE-test method. The statistical analysis was conducted with theχ2test with Yates correction at the 0.05 significance level (P≤0.05).Results. Between 2006 and 2008, 34% (39/115) ofH. pyloristrains were resistant to clarithromycin (primary 21% (19/90), secondary 80% (20/25)). 5% (6/115) of strains were resistant to levofloxacin (primary 2% (2/90), secondary 16% ((4/25); data published) Between 2009–2011, 22% (11/51) ofH. pyloristrains were resistant to clarithromycin (primary 19% (8/43), secondary 38% (3/8)). 16% (8/51) of strains were resistant to levofloxacin (primary 12% (5/43), secondary 38% (3/8)).Conclusion. The present study has shown the increasing amount of resistantH. pyloristrains isolated from patients in Southern Poland to levofloxacin and decreasing number of resistant strains to clarithromycin.
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Second-line levofloxacin-based triple therapy's efficiency for Helicobacter pylori eradication in patients with peptic ulcer. South Med J 2011; 104:579-83. [PMID: 21886067 DOI: 10.1097/smj.0b013e3182249be0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES First-line standard eradication efficacy with lansoprazole, amoxicillin and clarithromycin regressed over 10 years. The aim of this study was to evaluate the efficacy and tolerability of a levofloxacin-based regimen in patients with peptic ulcer after failure of the standard first-line H.pylori eradication therapy in a country with a high rate of infection. METHODS A total of 91 peptic ulcer patients who were diagnosed H.pylori positive proven by rapid urease test and histology between November 2005 to March 2008 were given lansoprazole 30 mg bid, amoxicillin 1 g bid and clarithromycin 500 mg bid (LAC) for 14 days. After three months from the first line eradication treatment omeprazole 20 mg bid, levofloxacin 500 mg bid, amoxicillin 1 g bid (OLA) 7 day treatment regimen was recommended as a second-line therapy for 37 patients who failed at first-line standard triple therapy. RESULTS Eradication rates for LAC regimen were found to be 57.14% (52/91) for intention to treat and 58.42% (52/89) for per protocol analysis. Eradication rates for OLA regimen were found to be 37.83% (14/37) for ITT and 41.17% (14/34) for PP analysis. CONCLUSION OLA regimen eradication rate was successful only in 40% of patients who failed in the first-line eradication. New eradication treatment strategies must be performed, at least in Turkey.
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Gisbert JP, Calvet X. Review article: non-bismuth quadruple (concomitant) therapy for eradication of Helicobater pylori. Aliment Pharmacol Ther 2011; 34:604-17. [PMID: 21745241 DOI: 10.1111/j.1365-2036.2011.04770.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Traditional standard triple therapy for Helicobacter pylori infection (PPI-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 (PPI-clarithromycin-amoxicillin-nitroimidazole) in the treatment of H. pylori infection. METHODS Bibliographical searches were performed in MEDLINE and relevant congresses. RESULTS The first randomised comparison of the non-bismuth quadruple therapy and the sequential (PPI-amoxicillin 5days plus PPI-clarithromycin-nitroimidazole 5days) regimens recently concluded that both were similar in terms of efficacy and safety and that the sequential administration protocol may be unnecessarily complex. Several randomised controlled trials (and one meta-analysis) have demonstrated that non-bismuth quadruple therapy is more effective than and is equally well tolerated as standard triple therapy. A meta-analysis of 15 studies (1723 patients) revealed a mean H. pylori cure rate (intention-to-treat) of 90% for non-bismuth quadruple therapy. A tendency towards better results with longer treatments (7-10days vs. 3-5days) has been observed, so it seems reasonable to recommend the length of treatment by achieving maximal cure rates (10days). 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. CONCLUSIONS 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.
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Affiliation(s)
- J P Gisbert
- Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IP), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
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Bohr URM, Malfertheiner P. Eradication of H. pylori Infection: the Challenge is on if Standard Therapy Fails. Therap Adv Gastroenterol 2011; 2:59-66. [PMID: 21180534 DOI: 10.1177/1756283x08100352] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The recommended standard triple therapy for Helicobacter pylori infection, consisting of a proton pump inhibitor, clarithromycin and amoxicillin or metronidazole, can reach eradication rates in over 90%. However, in recent years resistance to antibiotics has increased and eradication rates have declined. Approximately one in five patients need a second-line therapy because eradication therapy fails. Second-line treatment with a bismuth-based quadruple therapy leads to satisfactory eradication rates, but bismuth is not available in many countries. Modern second- and third-line treatments can only be successful if they are adapted to the current resistance situation and they need to evolve continuously. Moreover, pharmacodynamic effects due to polymorphisms of the cytochrome P450 system are important. Because therapy adherence is significantly associated with therapy success, modern regimens if possible should be easy to take and well tolerated. In recent years, various novel salvage-therapy regimens have been investigated that significantly improve treatment options.
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Affiliation(s)
- Ulrich R M Bohr
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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Hajimahmoodi M, Shams-Ardakani M, Saniee P, Siavoshi F, Mehrabani M, Hosseinzadeh H, Foroumadi P, Safavi M, Khanavi M, Akbarzadeh T, Shafiee A, Foroumadi A. In vitro antibacterial activity of some Iranian medicinal plant extracts against Helicobacter pylori. Nat Prod Res 2011; 25:1059-66. [DOI: 10.1080/14786419.2010.501763] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- M. Hajimahmoodi
- a Department of Drug and Food Control , Faculty of Pharmacy, Tehran University of Medical Sciences , Tehran , Iran
| | - M. Shams-Ardakani
- b Department of Pharmacognosy, Faculty of Pharmacy , Tehran University of Medical Sciences , Tehran , Iran
| | - P. Saniee
- c Department of Microbiology, Faculty of Sciences , University of Tehran , Tehran , Iran
| | - F. Siavoshi
- c Department of Microbiology, Faculty of Sciences , University of Tehran , Tehran , Iran
| | - M. Mehrabani
- d Pharmaceutics Research Center, Kerman University of Medical Sciences , Kerman , Iran
| | - H. Hosseinzadeh
- e Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences , Tehran , Iran
| | - P. Foroumadi
- e Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences , Tehran , Iran
| | - M. Safavi
- e Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences , Tehran , Iran
| | - M. Khanavi
- b Department of Pharmacognosy, Faculty of Pharmacy , Tehran University of Medical Sciences , Tehran , Iran
| | - T. Akbarzadeh
- e Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences , Tehran , Iran
| | - A. Shafiee
- e Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences , Tehran , Iran
| | - A. Foroumadi
- e Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences , Tehran , Iran
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Gisbert JP. Enfermedades relacionadas con Helicobacter pylori: dispepsia, úlcera y cáncer gástrico. GASTROENTEROLOGIA Y HEPATOLOGIA 2011. [DOI: 10.1016/s0210-5705(11)70003-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Assem M, El Azab G, Rasheed MA, Abdelfatah M, Shastery M. Efficacy and safety of Levofloxacin, Clarithromycin and Esomeprazol as first line triple therapy for Helicobacter pylori eradication in Middle East. Prospective, randomized, blind, comparative, multicenter study. Eur J Intern Med 2010; 21:310-4. [PMID: 20603042 DOI: 10.1016/j.ejim.2010.05.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 05/17/2010] [Accepted: 05/19/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Antibiotic resistance and poor compliance are the main causes of Helicobacter pylori (H. pylori ) eradication failure. This study evaluated the eradication rate, tolerability, and compliance of Levofloxacin, Clarithromycin and Esomeprazol combined triple therapy for H. pylori eradication. PATIENTS AND METHODS Four hundred-fifty patients from 3 centres who were diagnosed to have Helicobacter pylori infection by (13)C-urea breath test were randomized into 3 equal groups; group 1 (CAE) received Clarithromycin 500mg twice daily, Amoxicillin 1000mg twice daily, plus Esomeprazol 20mg twice daily for 7 days, group 2 (LAE) received Levofloxacin 500mg once daily, Amoxicillin 1000mg twice daily, plus Esomeprazol 20mg twice daily for 7 days, group 3 (CLE) received Levofloxacin 500mg once daily, Clarithromycin 500mg twice daily, plus Esomeprazol 20mg twice daily for 7 days. 436 patients were re-evaluated by (13)C-urea breath test after 6weeks from completion of treatment. RESULTS H. pylori eradication (intention to treat) was successful in 136/150 (90.6%) with CLE, 127/150 (84.7%) with LAE and 118/150 (78.6%) with CAE. There was a significant difference (p<0.001) regarding treatment success between CLE and LAE when compared with CAE. There was no difference among the treatment groups with regard to the incidence and severity of adverse events reported. CONCLUSION The combined Levofloxacin, and Clarithromycin and Esomeprazol based regimen as first line triple therapy for H. pylori eradication can give more significant eradication rate with same safety when compared with classic triple therapy.
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Affiliation(s)
- M Assem
- Hepatology Department, National Liver Institute, Sheben Al koom, Egypt.
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Li Y, Huang X, Yao L, Shi R, Zhang G. Advantages of Moxifloxacin and Levofloxacin-based triple therapy for second-line treatments of persistent Helicobacter pylori infection: a meta analysis. Wien Klin Wochenschr 2010; 122:413-22. [PMID: 20628905 DOI: 10.1007/s00508-010-1404-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Accepted: 05/14/2010] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The main aim of this meta-analysis was to compare the efficacy and safety of clarithromycin and second-generation fluoroquinolone-based triple therapy vs. bismuth-based quadruple therapy for the treatment of persistent Helicobacter pylori infection. METHODS A systematic literature search was conducted for articles and abstracts from 1981 to March 2009 using Medline, PubMed, EMBase, Google Scholar and CNKI (Chinese), Wanfang (Chinese) digital database and recent Digestive Disease Week, United European Gastroenterology Week, and European Helicobacter Study Group conferences were also performed. Boolean operators (NOT, AND, OR) were used in succession to narrow and widen the search. Sixteen articles and four abstracts met the inclusion criteria, and were included in the meta-analysis by using Review Manager 4.2.8. RESULTS The eradication rates demonstrated that clarithromycin-based triple therapy is inferior to bismuth-based quadruple therapy (OR = 0.53, 95% CI: 0.35-0.80, P = 0.002). Thirteen RCTs compared levofloxacin-based triple therapy vs. bismuth-based quadruple therapy, the eradication rates of the two regimens were shown to have no significant difference (OR = 1.43, 95% CI: 0.82-2.51, P = 0.21). But the eradication rates demonstrated superiority of the 10-day levofloxacin-based triple therapy over 7-day bismuth-based quadruple therapy (OR = 4.79, 95% CI: 2.95-7.79, P < 0.00001). Levofloxacin-based triple therapy was better tolerated than bismuth-based quadruple therapy with lower rates of side effects (OR = 0.41, 95% CI: 0.27-0.61, P < 0.0001), and lower rates of discontinuation of therapy due to adverse events (OR = 0.13, 95% CI: 0.06-0.33, P < 0.0001). Furthermore, our meta-analysis suggested that the eradication rates of the moxifloxacin-based triple therapy has a slight superiority to bismuth-based quadruple therapy, but there was no significant difference between them. CONCLUSION Second-generation fluoroquinolone-based triple therapy can be suggested as the regimen of choice for rescue therapy in the eradication of persistent H. pylori infection especially 10-day levofloxacin-based triple therapy.
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Affiliation(s)
- Yuqin Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Abstract
Helicobacter pylori infection is the main cause of gastritis, gastroduodenal ulcers and gastric cancer. H. pylori eradication has been shown to have a prophylactic effect against gastric cancer. According to several international guidelines, the first-line therapy for treating H. pylori infection consists of a proton pump inhibitor (PPI) or ranitidine bismuth citrate, with any two antibiotics among amoxicillin, clarithromycin and metronidazole, given for 7-14 days. However, even with these recommended regimens, H. pylori eradication failure is still seen in more than 20% of patients. The failure rate for first-line therapy may be higher in actual clinical practice, owing to the indiscriminate use of antibiotics. The recommended second-line therapy is a quadruple regimen composed of tetracycline, metronidazole, a bismuth salt and a PPI. The combination of PPI-amoxicillin-levofloxacin is a good option as second-line therapy. In the case of failure of second-line therapy, the patients should be evaluated using a case-by-case approach. European guidelines recommend culture before the selection of a third-line treatment based on the microbial antibiotic sensitivity. H. pylori isolates after two eradication failures are often resistant to both metronidazole and clarithromycin. The alternative candidates for third-line therapy are quinolones, tetracycline, rifabutin and furazolidone; high-dose PPI/amoxicillin therapy might also be promising.
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Affiliation(s)
- Hidekazu Suzuki
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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Matsuzaki J, Suzuki H, Tsugawa H, Nishizawa T, Hibi T. Homology model of the DNA gyrase enzyme of Helicobacter pylori, a target of quinolone-based eradication therapy. J Gastroenterol Hepatol 2010; 25 Suppl 1:S7-10. [PMID: 20586870 DOI: 10.1111/j.1440-1746.2010.06245.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Resistance of Helicobacter pylori to the standard therapeutic antimicrobial agents has been demonstrated. Although quinolones are an alternative candidate for third-line eradication therapy, quinolone resistance of H. pylori is also increasing. Quinolone resistance of H. pylori is caused by a point mutation of the DNA gyrase subunit A (GyrA) protein, especially on amino acids 87 and 91. The aim of this study is to surmise the structure of H. pylori GryA. METHODS The modeling of the 3-D structure of H. pylori GyrA was performed by an automated homology modeling program: SWISS-MODEL. The position of amino acids 87 and 91 in H. pylori GyrA was plotted on the homology model. To estimate the function of quinolone resistance-determining region (QRDR), the structure of H. pylori GyrA was compared with Escherichia coli GyrA. RESULTS A molecular model of H. pylori GyrA could be predicted using SWISS-MODEL. The GyrA N- and C-terminal domains closely resembled those of E. coli. The position of amino acids 87 and 91 in H. pylori GyrA was part of the DNA binding region (head dimer interface) on the GyrA N-terminal domain. CONCLUSION Our homology model of H. pylori GryA suggests that the quinolone resistance-determining region is on the head dimer interface of the GyrA N-terminal domain.
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Affiliation(s)
- Juntaro Matsuzaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Abstract
BACKGROUND Alternative treatment regimens for standard triple therapy are urgently needed. AIM To critically review the evidence on the role of "sequential" regimen for the treatment of Helicobacter pylori infection. METHODS Bibliographical searches were performed in MEDLINE and international congresses. RESULTS Several pooled-data analyses and meta-analyses have demonstrated that sequential regimen is more effective than standard triple therapy. Sequential therapy is not affected by bacterial (CagA status, infection density) and host factors (underlying disease, smoking). Clarithromycin resistance seems to be the only factor reducing their efficacy. However, even in these patients, an acceptable >75% eradication rate can be achieved. Unfortunately, almost all the studies have been performed in Italy. Whether it is necessary to provide the drugs sequentially or if the 4 components of sequential therapy can be given concurrently is unclear. Nonbismuth quadruple therapy seems to be an effective and safe alternative to triple therapy and is less complex than sequential therapy. CONCLUSIONS Sequential therapy is a novel promising treatment approach that deserves consideration as a treatment strategy for H. pylori infection. However, further robust assessment across a much broader range of patients is required before sequential therapy could supplant existing treatment regimens and be generally recommended in clinical practice.
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Gisbert JP, Calvet X, O'Connor JPA, Mégraud F, O'Morain CA. The sequential therapy regimen forHelicobacter pylorieradication. Expert Opin Pharmacother 2010; 11:905-18. [DOI: 10.1517/14656561003657152] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Abstract
Helicobacter pylori infection is the main known cause of gastritis, gastroduodenal ulcer disease and gastric cancer. After more than 20 years of experience in H. pylori treatment, however, the ideal regimen to treat this infection has still to be found. Nowadays, apart from having to know well first-line eradication regimens, we must also be prepared to face treatment failures. Therefore, in designing a treatment strategy we should not focus on the results of primary therapy alone, but also on the final (overall) eradication rate. The choice of a 'rescue' treatment depends on which treatment is used initially. If a first-line clarithromycin-based regimen was used, a second-line metronidazole-based treatment (quadruple therapy) may be used afterwards, and then a levofloxacin-based combination would be a third-line 'rescue' option. Alternatively, it has recently been suggested that levofloxacin-based 'rescue' therapy constitutes an encouraging second-line strategy, representing an alternative to quadruple therapy in patients with previous PPI-clarithromycin-amoxicillin failure, with the advantage of efficacy, simplicity and safety. In this case, quadruple regimen may be reserved as a third-line 'rescue' option. Finally, rifabutin-based 'rescue' therapy constitutes an encouraging empirical fourth-line strategy after multiple previous eradication failures with key antibiotics such as amoxicillin, clarithromycin, metronidazole, tetracycline, and levofloxacin. Even after two consecutive failures, several studies have demonstrated that H. pylori eradication can finally be achieved in almost all patients if several 'rescue' therapies are consecutively given. Therefore, the attitude in H. pylori eradication therapy failure, even after two or more unsuccessful attempts, should be to fight and not to surrender.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de la Princesa and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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Chang WL, Sheu BS, Cheng HC, Yang YJ, Yang HB, Wu JJ. Resistance to metronidazole, clarithromycin and levofloxacin of Helicobacter pylori before and after clarithromycin-based therapy in Taiwan. J Gastroenterol Hepatol 2009; 24:1230-5. [PMID: 19476562 DOI: 10.1111/j.1440-1746.2009.05829.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Clarithromycin-based triple therapy has been commonly applied as the first-line therapy for Helicobacter pylori eradication. Levofloxacin could serve as an alternative in either first-line or second-line regimens. This study surveyed the prevalence of levofloxacin resistance of H. pylori isolates in naive patients and in patients with a failed clarithromycin-based triple therapy. METHODS The study collected the H. pylori isolates from 180 naive patients and 47 patients with a failed clarithromycin-based triple therapy. Their in vitro antimicrobial resistance was determined by E-test. RESULTS The naive H. pylori isolates had resistance rates for amoxicillin, levofloxacin, clarithromycin and metronidazole of 0%, 9.4%, 10.6% and 26.7%, respectively. An evolutional increase of the primary levofloxacin resistance was observed in isolates collected after 2004, as compared to isolates collected before 2004 (16.3% vs 3.2%, P = 0.003). There was no evolutional increment of the primary clarithromycin resistance. The clarithromycin resistance elevated significantly after a failed clarithromycin-based triple therapy (78.7% vs 10.6%, P < 0.001). The post-treatment isolates remained to have a levofloxacin resistance rate of near 17%, but the levofloxacin-resistant isolates were correlated with a higher incidence of metronidazole resistance (P = 0.023). No strain was found to be resistant to amoxicillin even after eradication failure. CONCLUSION The levofloxacin resistance of naive H. pylori remains less than 10% in Taiwan. With relatively lower resistance to levofloxacin than to metronidazole of the H. pylori isolates collected after a failed clarithromycin-based therapy, proton pump inhibitor-levofloxacin-amoxicillin may be an alternative choice to serve as the second-line therapy.
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Affiliation(s)
- Wei-Lun Chang
- Department of Internal Medicine, Medical College, National Cheng Kung University, Tainan, Taiwan
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