Systematic review: Would susceptibility‐guided treatment achieve acceptable cure rates for second‐line Helicobacter pylori therapy as currently practiced?

Abstract

Background Susceptibility‐guided treatment has been proposed as a way to improve Helicobacter pylori eradication rates. Evidence on its efficacy for rescue therapy is very scarce. The aim of this study was to indirectly assess the applicability and effectiveness of susceptibility‐guided treatment by evaluating (a) the rate of acceptance of endoscopy, (b) its success in detecting resistances, and (c) infection cure rates in patients harboring strains found to be susceptible to the antibiotics administered in clinical trials in which the efficacy of second‐line treatments was reported. Methods A systematic review of studies evaluating second‐line H pylori treatment was carried out in multiple databases. Studies reporting antibiotic susceptibility evaluation and/or cure rates in patients harboring sensitive and resistant strains were selected. Data were extracted in duplicate. Results The systematic review identified 36 eligible studies. Acceptance was evaluated in only one study of 60 patients, of whom only 38 agreed to endoscopy. Among the 2890 patients who received endoscopy and culture, resistances were finally determined in 86.5%. Cure rate was 72.5% in the 113 patients harboring a clarithromycin‐susceptible strain after previous clarithromycin treatment, 93.5% in the 765 patients harboring a metronidazole‐susceptible strain, and 83.8% in the 192 patients harboring a levofloxacin‐susceptible strain. No studies with repeated administration of levofloxacin or metronidazole were found. Conclusion Even if the culture shows a clarithromycin‐sensitive strain, repeating clarithromycin after a first failure should be discouraged. Susceptibility‐guided treatment alone did not achieve adequate cure rates for rescue therapies. Additional measures are needed to design rescue treatments that consistently achieve excellent cure rates.

Resistance patterns of refractory Helicobacter pylori infection in a referral centre in the Delaware Valley

“…In the absence of a national registry other regional centres in the United States could consider a similar review of their available data to provide comparisons across regions, in order to help facilitate antibiotic therapy for refractory HP. Routine culture has so far not been recommended, as it is not clearly beneficial over empirical rescue therapy . Even in our study, given that culture rate was approximately 70%, many patients would undergo an endoscopy without subsequent culture results, and culture is certainly an imperfect test.…”

“…Routine culture has so far not been recommended, as it is not clearly beneficial over empirical rescue therapy. [26][27][28] Even in our study, given that culture rate was approximately 70%, many patients would undergo an endoscopy without subsequent culture results, and culture is certainly an imperfect test. Future studies should evaluate its role in guiding treatment and subsequently decreasing future antibiotic courses and therefore antibiotic resistance.…”

Review: Treatment of Helicobacter pylori Infection 2019

“…A German study looked at real-time genotypic clarithromycin and/or levofloxacin susceptibility as tested by PCR analysis of 144 H pylori-positive strains from patients with prior treatment failure. 35 From a first-line perspective in an area of high antibiotic resistance in South Korea, eradication rates of 93% were obtained for culture-based therapy. More encouraging results were obtained in a large, multicenter open-label trial of 450 patients who had failed two previous treatment regimes where genotypic resistance tailored treatment led to 78% eradication, but in this case empirical quadruple sequential therapy with a cure rate of 71% was an acceptable alternative after consideration of accessibility, cost, and patient preference.…”

“…34 A systematic review of 36 eligible studies on this topic, including 2890 patients, indicated a cure rate of 72% in the patients harboring clarithromycin-susceptible strains after previous clarithromycin treatment, 93% in the metronidazole-susceptible strains, and 84% in the levofloxacin-susceptible strains. 35 From a first-line perspective in an area of high antibiotic resistance in South Korea, eradication rates of 93% were obtained for culture-based therapy. 32 Separately, a study from China compared eradication rates for first-line susceptibility-guided treatment with bismuth-based quadruple therapy and found excellent eradication rates for both regimes, 92% and 85%, respectively.…”

Empirical or susceptibility‐guided treatment of refractory Helicobacter pylori infection?

“…Although susceptibility‐guided treatment has been proposed as a way to improve H pylori eradication rates, evidence on its efficacy for rescue therapy is very scarce. A recent systematic review found that susceptibility‐guided treatment alone did not achieve adequate cure rates for second‐line rescue therapies . Another systematic review concluded that, for third‐line therapy, performing culture is associated with cure rates which are, at best, moderate and this approach has never been compared with a well‐devised empirical therapy .…”