Efficacy of a 14-day quadruple-therapy regimen for third-line &lt;em&gt;Helicobacter pylori&lt;/em&gt; eradication

Background: Antibiotic resistance plays a crucial role in the treatment failure of Helicobacter pylori (H. pylori) infection. This study aimed to determine the trend of changes in the primary, secondary and tertiary antibiotic resistance of H. pylori in Taiwan over the last 7 years. Methods: We retrospectively analysed H. pylori-infected isolates from patients with primary resistance ( n = 1369), secondary resistance ( n = 196) and tertiary resistance ( n = 184) from January 2013 to December 2019. The H. pylori strains were tested for susceptibility to amoxicillin, clarithromycin, levofloxacin, metronidazole and tetracycline using the Epsilometer test method. Results: A progressively higher primary resistance rate was observed for clarithromycin (11.8–20.4%, p = 0.039 in χ2 test for linear trend), levofloxacin (17.3–38.8%, p < 0.001) and metronidazole (25.6–42.3%, p < 0.001) among naïve patients who received first-line eradication therapy. The dual primary resistance to clarithromycin and metronidazole also progressively increased in a linear trend (2.4–10.4%, p = 0.009). For secondary resistance, an increase was observed for levofloxacin (30.5–64.7%, p = 0.006) and metronidazole (40.5–77.4%, p < 0.001). For tertiary resistance, the observed increase was even more significant for levofloxacin (65.9–100.0%, p = 0.106) and metronidazole (44.4–88.2%, p < 0.001). The resistance to amoxicillin and tetracycline remained very low in Taiwan regardless of primary, secondary and tertiary resistance. Conclusion: Primary, secondary and tertiary antibiotic resistance to clarithromycin, levofloxacin and metronidazole for H. pylori has been increasing in Taiwan since 2013. Treatment should be targeted for eradication success rates of more than 90%. Third-line treatment should be based on antibiotic susceptibility.

show abstract

“…Vonoprazan-based regimens may play an important role in second-line H. pylori eradication therapy in the future. 36 …”

Section: Discussionmentioning

confidence: 99%

Trend of changes in antibiotic resistance in Helicobacter pylori from 2013 to 2019: a multicentre report from Taiwan

Liang

Tai

Hsu

et al. 2020

Therap Adv Gastroenterol

Self Cite

View full text Add to dashboard Cite

show abstract

“…We have just performed (in 2020) an updated meta-analysis comparing empirical versus susceptibility-guided treatment of H. pylori , 59 including 40 studies. 60–100 When only assessing first-line treatments, better efficacy results were obtained, overall, with the susceptibility-guided strategy (although the results were borderline statistically significant). However, when considering only empirical up-to-date first-line quadruple regimens (that is excluding the suboptimal triple therapies) no differences in efficacy were found versus the susceptibility-guided group.…”

Section: What Is the Comparative Effectiveness Of Susceptibility-guided Versus Empirical Strategy For First-line Treatment?mentioning

confidence: 97%

“…57 In our updated meta-analysis, only two studies including at least third-line rescue regimens were identified, and similar efficacy results were found between both tailored and empirical strategies. 86,88 The aim of a recent systematic review was to evaluate the effectiveness of susceptibility-guided therapy as third-line therapy (without comparing it with empirical treatment). 102 Four observational studies were included (no comparative studies were found), and the pooled mean eradication rate with susceptibility-guided therapy was only 72%.…”

Section: Susceptibility-based Strategy and Test-andtreat Strategy: A mentioning

confidence: 99%

Empirical or susceptibility-guided treatment for Helicobacter pylori infection? A comprehensive review

Gisbert

2020

Therap Adv Gastroenterol

View full text Add to dashboard Cite

Although susceptibility-guided therapy is frequently recommended for Helicobacter pylori infection, the evidence available to date supporting this strategy is limited. The aim of the present article is to review the advantages and limitations of the susceptibility-guided and the empirical strategies to treat this infection. We performed a bibliographic search to identify studies investigating H. pylori susceptibility-guided therapy. Culture is not the only way to assess antibiotic resistance, as different polymerase chain reaction-based approaches have been developed as alternative methods. For detecting H. pylori antimicrobial resistance, a molecular approach based on a stool sample might enable more convenient, time-saving methods. Unfortunately, the antimicrobial susceptibility cannot be obtained in all cases. Furthermore, antibiotic susceptibility testing in clinical practice yields useful information only for a few antibiotics: clarithromycin, metronidazole, and quinolones. In addition, susceptibility towards clarithromycin and metronidazole in vitro does not necessarily lead to eradication in vivo. In the case of H. pylori therapy failure, we should not re-administer any of the antibiotics against which H. pylori has probably become resistant. Our updated meta-analysis showed that susceptibility-guided treatment is not better than empirical treatment of H. pylori infection in first-line therapy if the most updated quadruple regimens are empirically prescribed, and similar efficacy results were also demonstrated with the two strategies for second-line therapy. Cumulative H. pylori eradication rate with several successive rescue therapies empirically prescribed reaches almost 100%. Finally, the studies that have evaluated the cost-effectiveness of the susceptibility-guided treatment have achieved contradictory results. In summary, we can conclude that the evidence is too limited to support the generalized use of susceptibility-guided therapy for H. pylori treatment in routine clinical practice, either as first-line or as rescue treatment. Nevertheless, it would be recommended that susceptibility tests are performed routinely, even before prescribing first-line treatment, in specialized centers with an interest in H. pylori management.

show abstract

“…15 Hybrid therapy has been proposed as a means of combining the benefits of the sequential and concomitant regimes but has been criticized as over-complicated and hence compromising on adherence to therapy. 18 Regarding the sequential therapy, which was proposed as a means of overcoming antibiotic resistance, an interesting study from Italy where H pylori primary resistance to antimicrobials tested is high showed eradication rates for 10-day sequential therapy of 97% in strains susceptible to clarithromycin and metronidazole, 96% in strains resistant to metronidazole, 93% in strains resistant to clarithromycin, and surprisingly even 83% in strains resistant to both clarithromycin and metronidazole. A randomized controlled trial of 352 patients in Taiwan found 96% eradication rates for both reverse hybrid and bismuth-based quadruple therapy.…”

Section: Quadruple Con Comitant S Equential and Hyb Rid Ther Amentioning

confidence: 99%

“…17 As a rescue therapy for third line in a highly resistant set of cases (79% resistant to clarithromycin, 95% to levofloxacin, and 67% to metronidazole), eradication rates of only 52% were seen for 14-day quadruple therapy, compared to 81% for susceptibilityguided treatment. 18 Regarding the sequential therapy, which was proposed as a means of overcoming antibiotic resistance, an interesting study from Italy where H pylori primary resistance to antimicrobials tested is high showed eradication rates for 10-day sequential therapy of 97% in strains susceptible to clarithromycin and metronidazole, 96% in strains resistant to metronidazole, 93% in strains resistant to clarithromycin, and surprisingly even 83% in strains resistant to both clarithromycin and metronidazole. 19…”

Section: Quadruple Con Comitant S Equential and Hyb Rid Ther Amentioning

confidence: 99%

Review: Treatment of Helicobacter pylori Infection 2019

et al. 2019

View full text Add to dashboard Cite

This review summarizes important studies regarding Helicobacter pylori therapy published from May 2018 to May 2019. The main themes that emerge involve studies assessing the efficacy of bismuth‐based regimens. While in recent years the efficacy of bismuth‐based quadruple therapy as a second‐line therapy has been clearly established, there is now substantial evidence that it is the best performing first‐line therapy. Antibiotic resistance was again intensely studied this year, and a clear and dramatic increase in resistance is noted for clarithromycin and levofloxacin; most notably, it may not be possible to support these therapies in most regions of the world much longer without testing. The utility of vonoprazan as an alternative to proton‐pump inhibitor therapy, especially in resistant and difficult to treat groups, has also been considered in greater detail this year, as well as means of supporting and enhancing adherence to therapy. Several studies showed that the diversity of gut microbiota was significantly altered shortly after H pylori eradication. However, the diversity was restored to pre‐treatment state after 2 months in patients treated with triple therapy. More studies are warranted to assess the long‐term changes of gut microbiota after H pylori eradication.

show abstract

Efficacy of a 14-day quadruple-therapy regimen for third-line <em>Helicobacter pylori</em> eradication

Cited by 13 publications

References 36 publications

Trend of changes in antibiotic resistance in Helicobacter pylori from 2013 to 2019: a multicentre report from Taiwan

Trend of changes in antibiotic resistance in Helicobacter pylori from 2013 to 2019: a multicentre report from Taiwan

Empirical or susceptibility-guided treatment for Helicobacter pylori infection? A comprehensive review

Review: Treatment of Helicobacter pylori Infection 2019

Contact Info

Product

Resources

About