Rifabutin for the Treatment of Helicobacter pylori Infection: A Review

Abstract

Nowadays, apart from having to know first-line Helicobacter pylori eradication regimens well, we must also be prepared to face treatment failures. The aim of this review is to summarize the role of rifabutin in the management of H. pylori infection. Bibliographical searches were performed in PubMed. Data on resistance and efficacy of rifabutin-containing regimens on H. pylori eradication were meta-analyzed. Mean H. pylori rifabutin resistance rate (39 studies, including 9721 patients) was 0.13%; when studies only including patients naïve to H. pylori eradication treatment were considered, this figure was even lower (0.07%). Mean H. pylori eradication rate (by intention-to-treat) with rifabutin-containing regimens (3052 patients) was 73%. Respective cure rates for second-, third-, fourth- and fifth-line therapies, were 79%, 69%, 69% and 72%. Most studies administered rifabutin 300 mg/day, which seemed to be more effective than 150 mg/day. The ideal length of treatment remains unclear, but 10–12-day regimens are generally recommended. Adverse events to rifabutin treatment in H. pylori studies were relatively infrequent (15%), and severe adverse events were exceptional (myelotoxicity was the most significant, although always reversible). In summary, rifabutin-containing therapy represents an encouraging strategy generally restricted, at present, to patients where previous (usually multiple) eradication regimens have failed.

Pitfalls of Physician-Directed Treatment of Helicobacter pylori: Results from Two Phase 3 Clinical Trials and Real-World Prescribing Data

“…Rifabutin is stable at a pH range of 2-8 and is not readily destroyed by stomach acid [14]. A recent review of 39 studies (9721 patients) concluded a resistance rate to rifabutin of < 1.0% (0.13%), and this rate fell to 0.07% in treatment-naïve patients [7]. Because H. pylori regimens are largely prescribed empirically, rifabutin-triple therapy (RHB-105) can be prescribed without concern for resistance.…”

Rescue Therapy with Furazolidone in Patients with at Least Five Eradication Treatment Failures and Multi-Resistant H. pylori infection

“…After failure of a third-line treatment, a fourth-line with rifabutin is generally recommended [ 7 ]. However, in the largest multi-centre study including this antibiotic, an eradication rate of 52% was reported [ 27 ], although a recent review reported an eradication rate of 73% [ 9 ]. All our patients had previously received (and failed) rifabutin treatment.…”

“…In some cases, H. pylori infection persists even after multiple eradication treatments. High-dose proton pump inhibitor–amoxicillin dual regimens or rifabutin-based therapies have generally been recommended for patients with several previous eradication failures [ 9 , 10 ], but these regimens also fail in some cases. It should be noted that these hyper-refractory cases are an extremely rare exception, with less than 1% of patients remaining infected with H. pylori after multiple (>4–5) eradication treatments [ 8 ].…”

Comments regarding use of rifabutin for Helicobacter pylori eradication

“…Non-Asian participants were evaluated based on the CYP2C19 genotype and there were no concerns with respect to safety or efficacy in poor metabolizing participants. Rifabutin has been used successfully for H pylori in Asians (Japan, Korea, and China), 4 and their exclusion in the trial should not be considered a reason not to use it in Asians. A second issue regarding rifabutin was that serious adverse reactions may occur, such as myelosuppression.…”

“…for H pylori treatment) and the emergence of rifabutin resistant TB. 4 Rifabutin is indicated for Mycobacterium avian intracellulare (MAI), which is an atypical bacterium and a rare disease associated with HIV-infected and immunocompromised hosts. Importantly, rifabutin is not a first line treatment for Mycobacterium tuberculosis (TB), but rather, is reserved for patients who cannot tolerate rifampicin or those with concerns of potential drug–drug interactions.…”