Efficacy of a 7-day course of furazolidone, levofloxacin, and lansoprazole after failed Helicobacter pylori eradication

Multiple Bismuth Quadruple Therapy Containing Tetracyclines Combined with Other Antibiotics and Helicobacter pylori Eradication Therapy

Helicobacter pylori (HP) infection is closely associated with the development of chronic gastritis, peptic ulcer, and gastric cancer. However, the resistance rate of H. pylori strains to antibiotics such as clarithromycin, metronidazole, and levofloxacin has increased significantly, resulting in a significant decrease in the eradication efficacy of commonly used regimens. Tetracycline has received the attention of domestic and foreign scholars because of its low resistance. The purpose of this review is to provide an update on the tetracycline-containing bismuth quadruple eradication therapy for H. pylori infection and review the efficacy and safety of the regimens, hoping to provide guidance for clinical practice.

Comparing Regimens Based on Clarithromycin, Furazolidone, and Levofloxacin in Patients With Helicobacter Pylori Infection: A Clinical Trial

Background: There is no current and broad consensus about the eradication of Helicobacter pylori (HP) infection in gastric ulcer and indigestion diseases. Objective: This study aimed to compare three regimens based on clarithromycin, furazolidone, and levofloxacin in patients with HP infection. Materials and Methods: This study was a randomized clinical trial examining 102 patients with gastrointestinal diseases. They were randomly assigned to three equal groups. In the first group, basic medication (i.e., a combination of esomeprazole 40 mg and amoxicillin 1000 mg) with clarithromycin 1000 mg was prescribed. The second group was treated with basic medication regimen along with furazolidone 400 mg. And the third group was given the basic medication with levofloxacin 500 mg. Eradication rates of the HP infection and incidence rates of drug side-effects in the three groups were compared after two-week and the obtained data were analyzed using appropriate statistical methods. Results: According to our study results, the HP infection eradication rates revealed by the per-protocol (PP) and intention-to-treat (ITT) analyses for the levofloxacin group were 91.2% and 93.8%, respectively, which were significantly different from those found for the furazolidone group by PP analysis and for the clarithromycin group by PP and ITT analyses (P<0.05). Moreover, there were no significant differences among the three groups regarding the side effects (P>0.05). Conclusion: It was concluded that two-week regimen of levofloxacin together with a single-dose of esomeprazole and amoxicillin was desirable (90%-95%) and more effective than furazolidone and clarithromycin in eradicating HP.

Systematic review, meta-analysis, and meta-regression: Successful second-line treatment for Helicobacter pylori

BACKGROUND

Multiple Helicobacter pylori second-line schedules have been described as potentially useful. It remains unclear, however, which are the best combinations, and which features of second-line treatments are related to better cure rates. The aim of this study was to determine that second-line treatments achieved excellent (>90%) cure rates by performing a systematic review and when possible a meta-analysis. A meta-regression was planned to determine the characteristics of treatments achieving excellent cure rates.

METHODS

A systematic review for studies evaluating second-line Helicobacter pylori treatment was carried out in multiple databases. A formal meta-analysis was performed when an adequate number of comparative studies was found, using RevMan5.3. A meta-regression for evaluating factors predicting cure rates >90% was performed using Stata Statistical Software.

RESULTS

The systematic review identified 115 eligible studies, including 203 evaluable treatment arms. The results were extremely heterogeneous, with 61 treatment arms (30%) achieving optimal (>90%) cure rates. The meta-analysis favored quadruple therapies over triple (83.2% vs 76.1%, OR: 0.59:0.38-0.93; P = .02) and 14-day quadruple treatments over 7-day treatments (91.2% vs 81.5%, OR; 95% CI: 0.42:0.24-0.73; P = .002), although the differences were significant only in the per-protocol analysis. The meta-regression did not find any particular characteristics of the studies to be associated with excellent cure rates.

CONCLUSION

Second-line Helicobacter pylori treatments achieving>90% cure rates are extremely heterogeneous. Quadruple therapy and 14-day treatments seem better than triple therapies and 7-day ones. No single characteristic of the treatments was related to excellent cure rates. Future approaches suitable for infectious diseases-thus considering antibiotic resistances-are needed to design rescue treatments that consistently achieve excellent cure rates.

Efficacy of levofloxacin, amoxicillin and a proton pump inhibitor in the eradication of Helicobacter pylori in Brazilian patients with peptic ulcers

OBJECTIVES

The eradication of Helicobacter (H.) pylori allows peptic ulcers in patients infected with the bacteria to be cured. Treatment with the classic triple regimen (proton pump inhibitor, amoxicillin and clarithromycin) has shown decreased efficacy due to increased bacterial resistance to clarithromycin. In our country, the eradication rate by intention to treat with this regimen is 83%. In Brazil, a commercially available regimen for bacterial eradication that uses levofloxacin and amoxicillin with lansoprazole is available; however, its efficacy is not known. Considering that such a treatment may be an alternative to the classic regimen, we aimed to verify its efficacy in H. pylori eradication.

METHODS

Patients with peptic ulcer disease infected with H. pylori who had not received prior treatment were treated with the following regimen: 30 mg lansoprazole bid, 1,000 mg amoxicillin bid and 500 mg levofloxacin, once a day for 7 days.

RESULTS

A total of 66 patients were evaluated. The patients' mean age was 52 years, and women comprised 55% of the sample. Duodenal ulcers were present in 50% of cases, and gastric ulcers were present in 30%. The eradication rate was 74% per protocol and 73% by intention to treat. Adverse effects were reported by 49 patients (74%) and were mild to moderate, with a prevalence of diarrhea complaints.

CONCLUSIONS

Triple therapy comprising lansoprazole, amoxicillin and levofloxacin for 7 days for the eradication of H. pylori in Brazilian peptic ulcer patients showed a lower efficacy than that of the classic triple regimen.

Comparison of quadruple and triple Furazolidone containing regimens on eradication of helicobacter pylori

BACKGROUND

The effectiveness of classic standard triple therapy regimen of helicobacter pylori (H. pylori) eradication has decreased to unacceptably low levels, largely related to development of resistance to metronidazole and clarithromycin. Thus successful eradication of H. pylori infections remains challenging. Therefore alternative treatments with superior effectiveness and safety should be designed and appropriately tested in all areas depending on the native resistance patterns. Furazolidone has been used successfully in eradication regimens previously and regimens containing furazolidone may be an ideal regimen.

METHODS

H. pylori infected patients with proven gastric or duodenal ulcers and /or gastric or duodenal erosions at Imam Khomeini Hospital in Sari/Northern Iran, were randomly allocated into three groups: group A (OABF) with furazolidone (F) (200 mg bid.), group B (OABM-F) metronidazole (M) (500 mg bid.) for the first five days, followed by furazolidone (F) (200 mg bid.) for the second five days and group C (OAF) with furazolidone (F) (200 mg tid.). Omeprazole (O) (20 mg bid.) and amoxicillin (A) (1000 mg bid.) were given in all groups; bismuth (B) (240 mg bid.) was prescribed in groups A & B. Duration of all eradication regimens were ten days. Eight weeks after treatment, a 14C-urea breath test was performed for evaluation of H. pylori eradication.

RESULTS

A total of 372 patients were enrolled in three groups randomly (124 patients in each group); 120 (97%) patients in group A (OABF), 120 (97%) in group B (OABM-F) and 116 (93%) in group C (OAF) completed the study. The intention-to-treat eradication rates were 83.7% (95% CI= 77.3-90.4), 79.8% (95% CI= 72.6-87), and 84.6% (95% CI= 78.2-91.1) and per-protocol eradication rates were 86.6% (95% CI= 80.5-92.8), 82.5% (95% CI= 75.6-89.4), and 90.5% (95% CI= 85.1-95.9) for groups OABF, OABM-F, and OAF, respectively. No statistical significant differences were found in case of severe drug adverse effects between the above mentioned three groups (p> 0.05). The most common side effects, namely nausea and fever, occurred in all groups, but more frequently in group C (OAF) (p< 0.05).

CONCLUSION

In developing countries such as Iran, furazolidone-based regimens can substitute clarithromycinbased regimens for H. pylori eradication because of a very low level of resistance, low cost and high effectiveness. Considering per-protocol eradication rate of ten days OAF regimen, and the acceptable limit of ninety percent, we recommend this regimen in developing countries such as Iran to be substituted of classic standard triple therapy. In order to minimize rare serious adverse effects, one week high dose OAF regimen should be taken into consideration in other studies.

Tetracycline- and furazolidone-containing quadruple regimen as rescue treatment for Helicobacter pylori infection: a single center retrospective study

BACKGROUND AND OBJECTIVE

Eradication rate of Helicobacter pylori decreases worldwide, while antibiotics resistance rates of H. pylori increase rapidly in recent years. In most cases, H. pylori would be resistant to clarithromycin, metronidazole, and quinolone if these antibiotics had been used as component of eradication regimen. H. pylori strains resistant to both tetracycline and furazolidone are rare. The aim of our study was to evaluate efficacy and side effects of tetracycline- and furazolidone-containing quadruple regimen as rescue treatment.

METHODS

Patients with H. pylori infection given RTFB (rabeprazole 20 mg b.i.d. + tetracycline 750 mg b.i.d. +furazolidone 100 mg b.i.d. + colloidal bismuth subcitrate 200 mg b.i.d.) regimen for 14 days as rescue treatment were enrolled in this retrospective study. Eradication status was evaluated by (13) C-urea breath test, and side effects were collected.

RESULTS

One hundred and nine patients were enrolled. The intention-to-treat eradication rate was 91.74% (100 of 109) and 95.24% (100 of 105) per protocol analysis. Side effects including fever, palpitation, and skin rash occurred in 35 patients.

CONCLUSIONS

The 14-day tetracycline- and furazolidone-containing quadruple regimen can achieve a relatively high eradication rate as rescue treatment. Some side effects including fever may occur during the treatment.

Low dose furazolidone for eradication of H- pylori instead of clarithromycin: a clinical trial

Background:

Helicobacter pylori infection is a common chronic human bacterial infection. Triple- therapy regimen containing a proton pump inhibitor, clarithromycin, and either amoxicillin or metronidazole is commonly used as first-line treatment for its eradication. However, it may not provide the acceptable eradication rate. The present study was designed to evaluated efficacy of low dose furazolidone with amoxicillin and omeprazole for eradication of H. pylori.

Materials and Methods:

One hundred twenty patients with non- ulcer dyspepsia or peptic ulcer confirmed by upper GI endoscopy, plus H. pylori infection confirmed by rapid urease test were included in the study. They were randomly divided into two groups, and then received clarithromycin, amoxicillin, and omeprazole, or furazolidone (100 mg PO bid), amoxicillin, and omeprazole. They were evaluated using urea breath test at the end of the study.

Findings:

The eradication rates were 57.6% and 78.8% in clarithromycin and furazolidone groups, respectively. Their difference was statistically significant (P value 0.013). No side effect was seen in the furazolidone group.

Conclusion:

Low dose furazolidone rather than clarithromycin can be used as low- cost and effective drug for eradication of H. pylori, in combination with amoxicillin and omeprazole.

Clinical management of Helicobacter pylori: the Latin American perspective

In most South American countries, Helicobacter pylori infection prevalence is high, affecting over 70% in populations with precarious living conditions. It is worth pointing out that there is initial evidence of a decline in prevalence of H. pylori infection at least in some more privileged fragments of the population. It is estimated that gastric cancer, the main clinical sequela of H. pylori infection, has an average incidence rate of 12.4 cases per 100,000 inhabitants (8.4 cases per 100,000 inhabitants for women and 17.3 cases per 100,000 for men) in the region. Classical triple therapy [proton pump inhibitor (PPI), amoxicillin and clarithromycin] is still the most used regimen with eradication rates around 80%. The rates of resistance to clarithromycin range from 2 to 24%. Recurrence rates of the infection are described as 2.9% in Argentina, 4.2% in Chile, 2-7% in Brazil, and 11.5% in a trial involving 7 Latin American countries. After failure of clarithromycin-containing regimens, second- and third-line therapies using PPI, amoxicillin and levofloxacin and quadruple therapy with PPI, colloidal bismuth subcitrate, tetracycline hydrochloride and metronidazole are recommended. Due to the high rates of primary resistance to metronidazole in the Latin American countries, use of the quadruple therapy, replacing metronidazole for furazolidone, is a frequent option. Rescue triple therapy regimens using furazolidone in association with levofloxacin and PPI have also been used. Most recommended rescue therapies reach eradication rates close to 80%.

Clarithromycin-based triple therapy for treatment of peptic ulcer in Helicobacter pylori-positive children

AIM: To observe the clinical efficacy of triple therapy with clarithromycin, metronidazole and omeprazole in the treatment of Helicobacter pylori (H. pylori) infection-related peptic ulcer in children.

METHODS: A retrospective analysis of 96 children with peptic ulcer associated with H. pylori infection treated at our hospital from July 2011 to July 2013 was performed. Depending on the treatment, the patients were divided into either a treatment group or a control group (n = 48 for each). The treatment group received triple therapy with clarithromycin, metronidazole and omeprazole, while the control group was treated with amoxicillin, metronidazole and omeprazole. After treatment, children in both groups underwent gastroscopy and H. pylori examination to compare clinical efficacy, rate of H. pylori eradication and adverse reactions.

RESULTS: The clinical efficacy was better in the treatment group than in the control group. The overall effective rate was significantly higher in the treatment group than in the control group (95.83% vs 70.83%, P < 0.05). Five weeks after treatment, the rate of H. pylori eradication was significantly higher in the treatment group than in the control group (87.50% vs 62.5%, P < 0.05). There was no significant difference in the incidence of adverse reactions between the two groups.

CONCLUSION: Triple therapy with clarithromycin, metronidazole and omeprazole is associated with a higher rate of H. pylori eradication and a lower rate of adverse reactions in the treatment of H. pylori infection-associated peptic ulcer in children.

Efficacy of PPI, levofloxacin and amoxicillin in the eradication of Helicobacter pylori compared to conventional triple therapy at a Venezuelan hospital

BACKGROUND AND STUDY AIMS

Helicobacter pylori is the main cause of gastritis, gastroduodenal ulcers and gastric cancer. In the past two decades, the recommended treatment for its eradication as a first-line regimen is the standard triple therapy consisting of a proton pump inhibitor (PPI), amoxicillin and clarithromycin or metronidazole. However, the effectiveness of this traditional regime, which initially was 90%, progressively declined in many parts of the world and is currently 57-73%. The aim of this study was to evaluate whether the eradication rate with triple therapy with levofloxacin is superior as first-line therapy to that with treatment using clarithromycin in the population that attended as outpatients at the Hospital of Lídice.

PATIENTS AND METHODS

We designed a prospective study, with two groups of patients presenting dyspeptic symptoms, from October 2010 to October 2011, who underwent upper gastrointestinal endoscopy and whose biopsies were positive for infection with H. pylori. At the end, 81 patients were included in the order of biopsy result arrival to fill the quota of each group. The first group with 42 patients underwent triple therapy with clarithromycin and the second group with 39 patients underwent therapy with levofloxacin, amoxicillin and a PPI. The patients' age ranged between 23 and 76years, the average being 49.5. The predominant sex was female, at 72.84%. Both treatments lasted for 10days and the patients were clinically re-evaluated 15days after their conclusion and programmed for a second endoscopy to verify H. pylori eradication.

RESULTS

Among the 42 patients in the control group, there were 14 eradication failures with 33.33% resistance to clarithromycin. Among the 39 patients in the experimental group, two eradication failures with 5.13% resistance to levofloxacin were observed. The χ(2) value was 6.96.

CONCLUSIONS

Treatment with levofloxacin was more effective than conventional triple therapy. Triple therapy with levofloxacin can be implemented in populations where resistance to clarithromycin has been observed.

A novel application of furazolidone: anti-leukemic activity in acute myeloid leukemia

Acute myeloid leukemia (AML) is the most common malignant myeloid disorder of progenitor cells in myeloid hematopoiesis and exemplifies a genetically heterogeneous disease. The patients with AML also show a heterogeneous response to therapy. Although all-trans retinoic acid (ATRA) has been successfully introduced to treat acute promyelocytic leukemia (APL), it is rather ineffective in non-APL AML. In our present study, 1200 off-patent marketed drugs and natural compounds that have been approved by the Food and Drug Administration (FDA) were screened for anti-leukemia activity using the retrovirus transduction/transformation assay (RTTA). Furazolidone (FZD) was shown to inhibit bone marrow transformation mediated by several leukemia fusion proteins, including AML1-ETO. Furazolidone has been used in the treatment of certain bacterial and protozoan infections in human and animals for more than sixty years. We investigated the anti-leukemic activity of FZD in a series of AML cells. FZD displayed potent antiproliferative properties at submicromolar concentrations and induced apoptosis in AML cell lines. Importantly, FZD treatment of certain AML cells induced myeloid cell differentiation by morphology and flow cytometry for CD11b expression. Furthermore, FZD treatment resulted in increased stability of tumor suppressor p53 protein in AML cells. Our in vitro results suggest furazolidone as a novel therapeutic strategy in AML patients.

3rd Brazilian Consensus on Helicobacter pylori

Signicant progress has been obtained since the Second Brazilian Consensus Conference on Helicobacter pylori Infection held in 2004, in São Paulo, SP, Brazil, and justify a third meeting to establish updated guidelines on the current management of H. pylori infection. The Third Brazilian Consensus Conference on H pylori Infection was organized by the Brazilian Nucleus for the Study of Helicobacter, a Department of the Brazilian Federation of Gastroenterology and took place on April 12-15, 2011, in Bento Gonçalves, RS, Brazil. Thirty-one delegates coming from the five Brazilian regions and one international guest, including gastroenterologists, pathologists, epidemiologists, and pediatricians undertook the meeting. The participants were allocated in one of the five main topics of the meeting: H pylori, functional dyspepsia and diagnosis; H pylori and gastric cancer; H pylori and other associated disorders; H pylori treatment and retreatment; and, epidemiology of H pylori infection in Brazil. The results of each subgroup were submitted to a final consensus voting to all participants. Relevant data were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded. Seventy per cent and more votes were considered as acceptance for the final statement. This article presents the main recommendations and conclusions to guide Brazilian doctors involved in the management of H pylori infection.

Helicobacter pylori antibiotic resistance in Brazil: clarithromycin is still a good option

CONTEXT

The antibiotic susceptibility is the cornerstone for the eradication therapies of Helicobacter pylori.

OBJECTIVES

To evaluate the prevalence of primary resistance of H. pylori was evaluated in an urban Brazilian population.

METHODS

H. pylori isolates were obtained from patients submitted to an upper gastrointestinal endoscopy for the evaluation of dyspeptic symptoms. Biopsies from antrum, corpus and fundus were taken to determine the antibiotic susceptibility of H. pylori isolates. The minimal inhibitory concentration of furazolidone and bismuth were routinely determined by agar dilution method and the minimal inhibitory for amoxicillin, clarithromycin, tetracycline, levofloxacin, and metronidazole were routinely determined with the E-test.

RESULTS

Fifty-four patients were included. In vitro antimicrobial susceptibility of H. pylori strains were obtained from 39 patients. Resistance to metronidazole was detected in 20 patients (51%), to clarithromycin in 3 patients (8%), to levofloxacin in 9 patients (23%) and to bismuth in 2 patients (5%). There was no observed resistance to amoxicillin, tetracycline or furazolidone.

CONCLUSION

Due to the low amoxicillin and clarithromycin resistance observed in this study, therapies using these antimicrobials remain appropriated first-line H. pylori therapy.

Rescue Therapy for Helicobacter pylori Infection 2012

Helicobacter pylori infection is the main cause of gastritis, gastroduodenal ulcer disease, and gastric cancer. After 30 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. In designing a treatment strategy, we should not only 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 2nd-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 3rd-line "rescue" option. 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.

Furazolidone-based therapies for Helicobacter pylori infection: a pooled-data analysis

BACKGROUND/AIM

Furazolidone-based therapies are used in developing countries to cure Helicobacter pylori infection due to its low cost. The low bacterial resistance toward furazolidone may render appealing the use of this drug even in developed countries. However, some relevant safety concerns do exist in using furazolidone.

PATIENTS AND METHODS

This was a systematic review with pooled-data analysis of data regarding both eradication rate and safety of furazolidone-based therapies for H. pylori infection. Intention-to-treat (ITT) and per-protocol (PP) eradication rates were calculated.

RESULTS

Following furazolidone-based first-line therapy, H. pylori eradication rates were 75.7% and 79.6% at ITT and PP analysis, respectively (P<0.001). The overall incidence of side effects and severe side effects were 33.2% and 3.8%, respectively. At multivariate analysis, only high-dose furazolidone was associated with increased therapeutic success (OR: 1.5, 95% CI: 1.3-2.7; P<0.001), while occurrence of side effects was relevant following treatment for a long duration (OR: 2.9, 95% CI: 2.2-4.1; P<0.001), high-dose furazolidone (OR: 2.3, 95% CI: 1.7-3.2; P<0.001) and bismuth-containing regimens (OR: 2.1, 95% CI: 1.5-2.8; P<0.001).

CONCLUSIONS

Furazolidone-based regimens usually achieve low eradication rates. Only a high-dose regimen improves the cure rate, but simultaneously increases the incidence of severe side effects. Therefore, we suggest that patients have to be clearly informed about the possible genotoxic and carcinogenetic effects for which furazolidone use is not approved in developed countries.

Inhibitory and bactericidal potential of crude acetone extracts of Combretum molle (Combretaceae) on drug-resistant strains of Helicobacter pylori

Infection with Helicobacter pylori is strongly associated with a number of gastroduodenal pathologies. Antimicrobial resistance to commonly-used drugs has generated a considerable interest in the search for novel therapeutic compounds from medicinal plants. As an ongoing effort of this search, the susceptibility of 32 clinical strains of H. pylori and a reference strain-NCTC 11,638-was evaluated against five solvent extracts of Combretum molle, a plant widely used for the treatment of gastric ulcers and other stomach-related morbidities in South Africa. The extracts were screened for activity by the agar-well diffusion method, and the most active one of them was tested against the same strains by micro-broth dilution and time kill assays. Metronidazole and amoxicillin were included in these experiments as positive control antibiotics. The solvent extracts all demonstrated anti-H. pylori activity with zone diameters of inhibition between 0 and 38 mm. The most potent anti-H. pylori activity was demonstrated by the acetone extract, to which 87.5% of the clinical strains were susceptible. The minimum inhibitory concentration (MIC90) values for this extract ranged from 1.25 to 5.0 mg/mL while those for amoxicillin and metronidazole ranged from 0.001 to 0.94 mg/mL and from 0.004 to 5.0 mg/mL respectively. The acetone extract was highly bactericidal at a concentration of 2.5 and 5.0 mg/mL, with complete elimination of the test organisms in 24 hours. Its inhibitory activity was better than that of metronidazole (p<0.05) as opposed to amoxicillin (p<0.05). The results demonstrate that C. molle may contain therapeutically-useful compounds against H. pylori, which are mostly concentrated in the acetone extract.

Aqueous and organic solvent-extracts of selected south African medicinal plants possess antimicrobial activity against drug-resistant strains of Helicobacter pylori: inhibitory and bactericidal potential

The aim of this study was to identify sources of cheap starting materials for the synthesis of new drugs against Helicobacter pylori. Solvent-extracts of selected medicinal plants; Combretum molle, Sclerocarya birrea, Garcinia kola, Alepidea amatymbica and a single Strychnos species were investigated against 30 clinical strains of H. pylori alongside a reference control strain (NCTC 11638) using standard microbiological techniques. Metronidazole and amoxicillin were included in these experiments as positive control antibiotics. All the plants demonstrated anti-H. pylori activity with zone diameters of inhibition between 0 and 38 mm and 50% minimum inhibitory concentration (MIC₅₀) values ranging from 0.06 to 5.0 mg/mL. MIC₅₀ values for amoxicillin and metronidazole ranged from 0.001 to 0.63 mg/mL and 0.004 to 5.0 mg/mL respectively. The acetone extracts of C. molle and S. birrea exhibited a remarkable bactericidal activity against H. pylori killing more than 50% of the strains within 18 h at 4× MIC and complete elimination of the organisms within 24 h. Their antimicrobial activity was comparable to the control antibiotics. However, the activity of the ethanol extract of G. kola was lower than amoxicillin (P < 0.05) as opposed to metronidazole (P > 0.05). These results demonstrate that S. birrea, C. molle and G. kola may represent good sources of compounds with anti-H. pylori activity.

Sequential metronidazole-furazolidone or clarithromycin-furazolidone compared to clarithromycin-based quadruple regimens for the eradication of Helicobacter pylori in peptic ulcer disease: a double-blind randomized controlled trial

BACKGROUND

Furazolidone is a much cheaper drug with a very low resistance against Helicobacter pylori compared to clarithromycin. We aim to evaluate safety and efficacy of a sequential furazolidone-based regimen versus clarithromycin-based therapy in H. pylori eradication for ulcer disease.

MATERIALS

Patients with proven peptic ulcer or duodenitis were randomized into three groups: OAB-M-F; metronidazole (M) (500 mg bid) for the first 5 days, followed by furazolidone (F) (200 mg bid) for the second 5 days; OAC-P; clarithromycin (C) (500 mg bid) for 10 days; and OAB-C-F; clarithromycin (500 mg bid) for the first 5 days and furazolidone (200 mg bid) for the second 5 days. All groups received omeprazole (O) (20 mg bid) and amoxicillin (A) (1 g bid). Groups OAB-M-F and OAB-C-F were also given bismuth subcitrate (B) (240 mg bid), whereas a placebo (P) was given to group OAC-P. Adverse events were scored and recorded. Two months after treatment, a C(13) -urea breath test was performed.

RESULTS

Three hundred and ten patients were enrolled and 92 (OAB-M-F), 95 (OAC-P), and 98 (OAB-C-F) completed the study. The intention-to-treat eradication rates were 78.5% (95% CI = 69-85), 81.1% (95% CI = 73-88), and 82% (95% CI = 74-89), and per-protocol eradication rates were 91.3% (95% CI = 83-96), 90.4% (95% CI = 82-95), and 88.7% (95% CI = 81-94), for group OAB-M-F, OAC-P, and OAB-C-F, respectively. Eradication rate differences did not reach statistical significance. The most common adverse event, bad taste, occurred in all groups, but more frequently in groups OAC-P (34%) and OAB-C-F (32%), than OAB-M-F (14%) (p < .05). Adverse symptoms score were 0.88 ± 2.05 in group OAB-M-F, 1.15 ± 1.40 in group OAC-P, and 1.87 ± 1.62 in group OAB-C-F.

CONCLUSION

Furazolidone can replace clarithromycin in H. pylori eradication regimens because of lack of development of resistance and very low cost.

Treatment of Helicobacter pylori infection 2010

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

Distribution of gyrA mutations in fluoroquinolone-resistant Helicobacter pylori strains

AIM: To investigate the resistance of Helicobacter pylori (H. pylori) to ciprofloxacin (CIP), levofloxacin (LVX) and moxifloxacin (MOX) in the Beijing area and to elucidate the resistance mechanisms.

METHODS: Seventy-nine H. pylori clinical strains, isolated from patients who had undergone upper gastrointestinal endoscopy in Peking University First Hospital from 2007 to 2009, were tested for their susceptibility to CIP, LVX and MOX using the E-test method. H. pylori strain 26695 was included in the susceptibility testing as a control strain. According to the minimal inhibitory concentration (MIC) values, a strain was classified as resistant to CIP, LVX or MOX when the MIC was > 1 μg/mL. We amplified by polymerase chain reaction (PCR) and sequenced the quinolone resistance-determining regions of the gyrA and gyrB genes from 29 quinolone-resistant and 16 quinolone-susceptible H. pylori strains selected at random.

RESULTS: In this study, the resistance rates of H. pylori to CIP, LVX or MOX were 55.7% (44/79), and the primary resistance rates were 26.6% (21/79). Patients with secondary resistance had received LVX in previous eradication treatments, but not MOX or CIP. Forty-five strains, including 29 CIP, LVX or MOX-resistant strains (MIC: 1.5-32 μg/mL) and 16 susceptible strains, were selected randomly from the 79 strains and used in PCR analysis. Among these 45 strains, 27 resistant strains had mutations in the gyrA gene, including 11 strains with mutations corresponding to Asp-91 (MIC: 2-32 μg/mL), one of which also had a mutation corresponding to Val-150, and 16 strains had mutations at Asn-87 (MIC: 4-32 μg/mL), three of which also had mutations corresponding to Arg-140 or Val-150. In addition, Arg-140, Val-150 or Ala-97 mutations were separately detected in three susceptible strains. Analysis of the gyrB gene showed that one strain of low resistance had a mutation corresponding to Ser-457 that coexisted with an Asp-91 mutation. There was a significant difference in the occurrence of mutations in the gyrA gene between CIP, LVX and MOX-resistant and -susceptible strains (P < 0.05), but 2 resistant strains were found to possess no quinolone resistance-determining region mutations.

CONCLUSION: Resistance is primarily mediated through point mutations in gyrA. Whether other mechanisms are responsible for resistance in strains without mutations in the QRDR should be detected.

Helicobacter pylori: diagnosis and treatment

PURPOSE OF REVIEW

Multiple diagnostic methods and treatment strategies have been developed to detect and treat the Helicobacter pylori infection. Many of them have stood the test of time; others lost their value with the introduction of new test and treatment modalities. This review focuses on the current diagnostic methods and their clinical implications, as well as on established and novel treatment strategies.

RECENT FINDINGS

The increasing antimicrobial resistance has resulted in a decline of the success rate of recommended eradication regimens. The current guidelines recommend as first-line treatment clarithromycin, amoxicillin or metronidazole, and proton pump inhibitor twice daily, but recent studies have demonstrated an increasing eradication failure with these regimens. Several treatment modifications have been adopted regarding duration and combination of substances.

SUMMARY

The currently recommended first-line treatments are effective and well tolerated. In areas with high antimicrobial resistance rates, new antibiotic combinations and modifications in the sequence of drug administration are proposed as alternative treatment options to standard triple therapy. Future treatment strategies have to focus on regional antimicrobial resistance adopted treatment selection and the development of new antibiotics.

Second-line rescue therapy of helicobacter pylori infection

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.