The Clinical and Bacteriological Factors for Optimal Levofloxacin-Containing Triple Therapy in Second-Line Helicobacter pylori Eradication

Abstract

Quinolone has the disadvantage of easily acquired drug resistance. It is important to prescribe it wisely for a high eradication rate. The current study aimed to determine the clinical and bacteriological factors for optimal levofloxacin-containing triple therapies in second-line H. pylori eradication. We enrolled a total of 158 H. pylori-infected patients who failed H. pylori eradication using the 7-day standard triple therapy (proton-pump inhibitor [PPI] twice daily, 500 mg clarithromycin twice daily, and 1 g amoxicillin twice daily). They were prescribed with either a 10-day (group A) or 14-day (group B) levofloxacin-containing triple therapy group (levofloxacin 500 mg once daily, amoxicillin 1 g twice daily, and esomeprazole 40 mg twice daily for 10 days) by their clinicians. Follow-up studies to assess treatment responses were carried out 8 weeks later. The eradication rates attained by groups A and B were 73.6% (95% confidence interval [CI] = 63.9–85.3%) and 90.5% (95% CI = 84.5–98.1%), respectively in the per protocol analysis (P = 0.008 in the per protocol analysis) and 67.1% (95% CI = 56.6–78.5%) and 84.8% (95% CI = 76.8–93.4%), respectively, in the intention-to-treat analysis (P = 0.009). The subgroup analysis revealed that H. pylori eradication rates for group A patients with levofloxacin-susceptible strains were 92.9% (13/14) but it dropped to 12.5% (1/8) when levofloxacin-resistant strains existed. H. pylori was eradicated among all the group B patients with levofloxacin-susceptible strains, but only half of patients with levofloxacin-resistant strains were successfully eradicated. In conclusion, this study confirms the effectiveness of 14-day treatment. Importantly, the results imply that 10-day treatment duration should be optimal if a culture can be performed to confirm the existence of susceptible strains. The duration of H. pylori eradication and levofloxacin resistance were the influencing factors for successful treatment. This study suggests that tailored levofloxacin-containing therapy should be administered only for patients with susceptible strains because it can achieve >90% success rates.

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

“…Studies reporting duplicate data were excluded. After careful evaluation, 36 studies (including 3466 patients) were found to perform antibiotic susceptibility determinations and were included in the systematic review. Of these 36 articles, 24 reported cure rates according to antibiotic resistances/susceptibilities, including 37 arms of treatment.…”

“…Nine additional articles performed endoscopy in all patients but did not state whether the procedure was an inclusion criteria or whether patients who rejected endoscopy had been excluded . In another 10 articles, endoscopy was not performed in all patients but the reasons for not doing so were not stated, nor whether endoscopy was offered to all patients . In this group, endoscopy was performed in 682 of the 1189 patients included (57.4%).…”

“…16,18,38,40,41,43,44 In another 10 articles, endoscopy was not performed in all patients but the reasons for not doing so were not stated, nor whether endoscopy was offered to all patients. 17,[20][21][22]25,30,32,42,47 In this group, endoscopy was performed in 682 of the 1189 patients included (57.4%). Only one article specified that all the 60 patients included were offered endoscopy and that only 38 (63.3%) accepted.…”

Systematic review, meta‐analysis, and meta‐regression: Successful second‐line treatment forHelicobacter pylori

“…Of these, 61 arms (30%) showed PP cure rates >90% . Two studies (two arms) evaluated a dual therapy (rabeprazole and amoxicillin), 34 arms evaluated a triple therapy (Table ), and 25 arms evaluated quadruple therapies (Table ).…”

Two-week Triple Therapy with either Standard or High-dose Esomeprazole for First-line H. pylori Eradication

“…Worth noting is that such a therapy achieved an encouragingly high (87.5%) eradication rate. A similarly prolonged levofloxacin-based triple, with double-dose PPI, achieved 84.8-93.6% success rates in Taiwan [24,25]. However, when a regimen with increased doses was administered for only 8 days, the eradication rate was only 60-64% [26].…”