Efficacy of second-line regimens forHelicobacter pylorieradication treatment: a systemic review and network meta-analysis

Abstract

BackgroundCurrent guidelines recommend bismuth-containing quadruple therapy (BQT) and quinolone-containing therapy after failure of first-line Helicobacter pylori eradication therapy. However, the optimum regimen of second-line eradication therapy remains elusive. We conducted a network meta-analysis to compare the relative efficacy of 16 second-line H. pylori eradication regimens.MethodsThree major bibliographic databases were reviewed to enrol relevant randomised controlled trials between January 2000 and September 2018. Network meta-analysis was conducted by STATA software and we performed subgroup analysis in countries with high clarithromycin resistance and high levofloxacin resistance, and in patients with documented failure of first-line triple therapy.ResultsFifty-four studies totalling 8752 participants who received 16 regimens were eligible for analysis. Compared with a 7-day BQT, use of probiotic add-on therapy during, before, and after second-line antibiotic regimens, quinolone-based sequential therapy for 10–14 days, quinolone-based bismuth quadruple therapy for 10–14 days, bismuth quadruple therapy for 10–14 days, and quinolone-based triple therapy for 10–14 days were significantly superior to the other regimens. Subgroup analysis of countries with high clarithromycin resistance and high levofloxacin resistance revealed that the ranking of second-line eradication regimens was distributed similarly in each group, as well as in patients with failure of first-line triple therapy.ConclusionWe conducted a detailed comparison of second-line H. pylori regimens according to different antibiotic resistance rates and the results suggest alternative treatment choices with potential benefits beyond those that could be achieved using salvage therapies recommended by guidelines.

Empiric “Three-in-One” Bismuth Quadruple Therapy for Second-Line Helicobacter pylori Eradication: An Intervention Study in Southern Italy

“…Among other conventional second-line regimens, the levofloxacin-based triple therapy is, if BQT lasts 10 or 14 days, equally effective, as outlined by a meta-analysis [ 20 ]. Consequently, Canadian guidelines have suggested extending the duration of BQT to 14 days in order to optimize eradication [ 21 ].…”

Management ofHelicobacter pyloriinfection: the Maastricht VI/Florence consensus report

“…A systematic review and NWM including 54 RCTs found that quinolone-based triple (ie, PPI, levofloxacin and amoxicillin) or quadruple therapy (ie, PPI, levofloxacin, bismuth and amoxicillin or tetracycline) administered for at least 10 days, was more effective than bismuth-containing quadruple therapy as a second-line treatment. 248 Recent warnings about serious adverse effects of fluoroquinolones have been issued, restricting their use to infections in which the therapeutic benefit outweighs the risks, and this should be the case. Using a clarithromycin-containing treatment after failure of a BQT might not be practical since bismuth-based therapies are usually proposed as first-line treatments for areas of high clarithromycin resistance.…”

Levofloxacin versus clarithromycin for Helicobacter pylori eradication: are 14 day regimens better than 10 day regimens?

“…The main determinants of successful H. pylori eradication include assessment of pretreatment resistance to antimicrobial agents, treatment duration, regimen type, and patient compliance [ 7 ]. Additionally, there has been a debate about the relationship between H. pylori infection and diabetes as some studies showed an increased risk of infection in diabetic patients and a lower eradication rate [ 8 , 9 ].…”