Pharmacological considerations and step-by-step proposal for the treatment of Helicobacter pylori infection in the year 2018

Abstract

Over the past 30 years, multidrug regimens consisting of a proton pump inhibitor (PPI) and two or three antibiotics have been used in treating Helicobacter pylori (H. pylori) infection. In clinical practice, the optimal regimen to cure H. pylori infection should be decided regionally. Considering the first treatment, the Maastricht V/Florence Consensus Report and the American College of Gastroenterology Clinical Management Guideline highlight that in countries with low clarithromycin resistance rates (<15%), an empiric clarithromycin-based regimen can be used. In countries with high clarithromycin resistance rates or, in the American Guideline, with a previous exposure to clarithromycin, a bismuth-containing quadruple therapy (with metronidazole and tetracycline) is the first choice. In case of persistent infection, after a previous clarithromycin-containing regimen, this drug should be avoided in second line therapy. Options after initial eradication failure include tailored therapy (choosing antibiotic combinations based on antibiotic susceptibility testing), empiric bismuthcontaining quadruple therapy or triple levofloxacin-based therapy. Encouraging data are reported, both for the first-line and for rescue treatments, with the use of a formulation of bismuth subcitrate potassium, metronidazole, and tetracycline contained in a single capsule, together with a PPI. Rifabutin-and furazolidone-based regimens should also be considered in rescue regimens. Vonoprazan, a new type of potassium-competitive acid blocker that produces more potent acid inhibition than PPIs, provides improved H. pylori eradication rates in combination with antibiotics. In this review, the authors provide an overview on the current knowledge on the treatment of H. pylori infection, with focus on therapeutic challenges in this field.

Evaluation of the Direct Economic Cost per Eradication Treatment Regimen against Helicobacter pylori Infection in Greece: Do National Health Policy-Makers Need to Care?

“…High antibiotic resistance has provoked a gradual escalation of eradication treatment regimens, following an "add-on" strategy, especially in regions such as in Greece where bismuth containing medications are not commercially available [18,24,25]. Hp resistance to clarithromycin (>20%) has been recognized as the most determinant hindrance of eradication treatment success [26] and in that setting, quadruple regimens are indicated [10,27]. However, in Greece, despite clear statements in current guidelines, some practitioners (especially non-gastroenterologists) insist on prescribing triple regimens.…”

Two-week bismuth-containing quadruple therapy and concomitant therapy are effective first-line treatments for Helicobacter pylori eradication: A prospective open-label randomized trial

“…However, H. pylori is becoming resistant to previously efficacious antibiotic regimens[2]. Clarithromycin resistance is increasing worldwide[2-4]. The eradication rate afforded by legacy triple therapy (LTT) (the historical first-line treatment for H. pylori infection; LTT includes clarithromycin) has declined over the past decade, and has decreased to near 80% or below in some countries of Asia and Europe[2-4].…”

“…Clarithromycin resistance is increasing worldwide[2-4]. The eradication rate afforded by legacy triple therapy (LTT) (the historical first-line treatment for H. pylori infection; LTT includes clarithromycin) has declined over the past decade, and has decreased to near 80% or below in some countries of Asia and Europe[2-4]. Dual clarithromycin-/metronidazole-resistance of H. pylori is also of concern worldwide[5].…”

Rifabutin and Furazolidone Could Be the Candidates of the Rescue Regimen for Antibiotic-Resistant H. pylori in Korea

“…H. pylori is recognized as a Class I carcinogen by the International Agency for Research on Cancer and the World Health Organization [1–3]. The eradication of antibiotic-resistant H. pylori is a global health issue [4].…”

“…However, multidrug-resistant (MDR) strains of H. pylori have been increasing worldwide due to the increased use of antibiotics [1, 2, 4–9]. In Korea, the rate of H. pylori eradication has declined steadily in recent decades as a result of increasing resistance to antibiotics, especially dual resistance to clarithromycin and metronidazole [10–12] which has resulted from the increased clinical use of macrolides and metronidazole [13, 14].…”