Second line therapy for Helicobacter pylori eradication: state of art

Helicobacter pylori Secondary Antibiotic Resistance after One or More Eradication Failure: A Genotypic Stool Analysis Study

Helicobacter pylori (H. pylori) antibiotic resistance is the leading cause for unsuccessful eradication therapy. After one or more failures, the chance of encountering secondary antibiotic resistance increases. The aim of this study was to characterize genotypic secondary resistance in a cohort of southern Italian H. pylori patients with at least one previous failure. Such patients collected stool samples using a dedicated kit (THD fecal testTM), and bacterial DNA was extracted and amplified using RT-PCR. Resistance to clarithromycin, amoxicillin, metronidazole, levofloxacin, and tetracycline was assessed using a high-resolution melting curve. We enrolled 50 patients. A total of 72% of patients failed one previous antibiotic course, 16% failed two, 10% failed three, and 2% failed four. The rate of secondary antibiotic resistance was 16% for clarithromycin, 18% for metronidazole, 14% for amoxicillin, 14% for levofloxacin, and 2% for tetracycline. Among the eight clarithromycin-resistant patients, five (62.5%) previously received a clarithromycin-based regimen. The same rate was 33.3% (3/9) for metronidazole. The only tetracycline-resistant patient had received Pylera. In conclusion, our data seem to show that, even though secondary resistance is not very high, resistance to clarithromycin could be very likely related to previous exposure to this antibiotic.

Efficacy and tolerability of Helicobacter pylori eradication regimes in South Kivu, Eastern of the Democratic Republic of Congo: A single center observational study

Background and Aims

Treating Helicobacter pylori infections has become a major challenge due to increased antibiotic resistance. The aim of this study was to investigate the efficacy and tolerability of the main standard regimens recommended for H. pylori eradication in Bukavu, Eastern of the Democratic Republic of Congo.

Methods

The study enrolled patients with evidence of H. pylori infection in histological examination or serology testing combined with a positive fecal antigen test. As first-line treatment, patients were randomized to either a 10-days (OAC-10) or a 14-days (OAC-14) regimen, employing a combination of omeprazole 20 mg, amoxicillin 1 g, and clarithromycin 500 mg twice daily. In case of failure, a second line regimen was evaluated and included two others protocols: OAC-10 regimen + levofloxacin 500 mg (OAC-10+) and the bismuth-based therapy (pantoprazole + bismuth salt + metronidazole + tetracycline) during 10 days. Our primary endpoint was H. pylori eradication and secondarily, the compliance and adverse effects were also evaluated.

Results

A total of 179 patients were enrolled. The eradication rate was 79.2% and 80.5% with the OAC-10 and OAC-14 regimen, respectively (p = 0.796). Adverse effects were significant higher in the OAC-14 group than in the OAC-10 group (36.5% vs. 57.8%; p < 0.001). On the other hand, the compliance rate was slightly higher in the OAC-10 group (97.9% vs. 91.6%, p = 0.052) while clinical improvement was almost similar in both groups. Regarding the second line regimen, the bismuth-based therapy (n = 18) seemed to show a better response with 100% of eradication rate and 100% of clinical improvement.

Conclusion

The classic 10-days triple therapy seems to be as effective as the 14-days regimen while having in addition a good tolerance. Apart from cost issues, the bismuth-based therapy seems to be a very good alternative in case of first-line treatment failure.

Clinical Implications of Helicobacter pylori Antibiotic Resistance in Italy: A Review of the Literature

Helicobacter pylori (H. pylori) resistance to antibiotics has increased worldwide in recent decades, especially to clarithromycin. As a result, the World Health Organization (WHO) identified clarithromycin-resistant H. pylori as a "high priority" pathogen in 2017. As international guidelines recommend empirical therapy as first-line treatment, it is crucial to know local resistance rates and history of antibiotic use to determine the most appropriate first-line antibiotic treatment. Italy is one of the European countries with the highest prevalence of H. pylori infection and the highest percentage of antibiotic-resistant H. pylori. The aim of this review is to summarize all data on H. pylori antibiotic resistance in Italy in order to quantify the current rate and determine the most effective therapeutic approach. The study confirms an elevated level of resistance to clarithromycin, metronidazole, and levofloxacin in Italy. In addition, our results show a satisfactory eradication rate for a bismuth-based regimen when used as first- or second-line treatment. Naive patients are also successfully treated with clarithromycin-based quadruple therapies. Considering the good results of bismuth-based therapy as recovery therapy, this argues for the potential use of clarithromycin quadruple therapy as a first-line treatment.

Treatment of refractory Helicobacter pylori infection: A new challenge for clinicians

Patients who have failed two or more attempts to eradicate Helicobacter pylori are commonly referred to as refractory. Although the incidence of refractory Helicobacter pylori infection is only 10–20%, with the increasing rate of antibiotic resistance in various regions, the treatment of refractory Helicobacter pylori infection has gradually become a difficult problem faced by clinicians. When choosing a rescue therapy, the physician must consider numerous factors. A longer treatment duration, higher doses of proton pump inhibitors (PPIs), or the use of potassium-competitive acid blocker (P-CAB) may increase the efficacy of triple therapy or bismuth quadruple therapy. Rescue treatment based on bismuth quadruple therapy usually achieves better results. At the same time, treatment based on drug susceptibility tests or genotypic resistance is recommended where available. Of course, appropriate empiric treatment can also be selected according to local drug resistance, a patient’s previous medication history and compliance. It is the best choice if it can improve the success rate of the first treatment and reduce the occurrence of refractory Helicobacter pylori infection. This review aims to summarize the articles related to refractory Helicobacter pylori in recent years and to explore a better remedial treatment plan for clinicians.