Treatment of Helicobacter pylori Infection 2015

Abstract

Many interesting articles have been published from many parts of the world over the last year assessing different issues around Helicobacter pylori eradication therapy. This article will address the published literature over the last year pertaining to the topic of treatment of H. pylori infection. The main themes that emerge are assessing the efficacy of standard triple therapy, as well as exploring new first-line treatments, mainly optimized nonbismuthand bismuth-containing quadruple therapies with some promising data also emerging on dual therapy. There was also considerable progress in investigating antibiotic resistance rates with much more data emerging from varied parts of the world compared to recent years. There have also been advances in the use of adjunctive therapies, especially probiotic therapies. Undoubtedly, the eradication of H. pylori remains a worthwhile goal to alleviate the burden of diseases caused by the complications of this infection, including dyspepsia, peptic ulcer disease, and gastric cancer. Triple TherapyA number of studies have been published this year, primarily from Asia, on standard triple therapy which remains the regimen recommended in the majority of published guidelines. A meta-analysis from China showed suboptimal eradication rates in this part of the world with a pooled rate of 74.5% which was inferior when compared to sequential therapy with relative risk (RR) = 0.863 [1]. Better, but still insufficient, eradication rates however were noted in Korea, with an overall eradication rate of 84% from 2005 to 2010 [2]. In Japan, while rates remain clearly suboptimal, eradication rates by per-protocol (PP) analysis have not changed between 2001 and 2010 although there has been a decline in eradication rates by intention-to-treat (ITT) analysis [3]. Another Japanese group from a region of higher clarithromycin resistance compared 7-day standard triple therapy with rabeprazole, amoxicillin, and clarithromycin (RAC) to rabeprazole, amoxicillin, and metronidazole (RAM). They found ITT eradication rates of 73% in the RAC group and 91% in the RAM group [4]. In other regions, a study in Nigeria found an eradication rate of 87% for triple therapy with no difference between 7 and 10 days of treatment [5]. An interesting study from Spain showed that when clarithromycin susceptibility testing is carried out prior to treatment, eradication rates reach 94% compared to 72% for empiric treatment, based on a 10-day regimen [6]. Similar findings emerged from a Japanese study where 97% eradication was achieved when antimicrobial susceptibility testing was carried out prior to treatment, and it was 95% eradication in a Korean study [7,8]. Another study from Spain examined the optimal first-line eradication regimen for patients with penicillin allergy and reported ITT eradication rates with omeprazole-clarithromycin-metronidazole of only 57% compared to 74% for PPI-bismuth-tetracyclinemetronidazole, with equivalent rates of compliance and adverse events. In this specific group for second-line treat...

Importance of antimicrobial susceptibility testing for the management of eradication inHelicobacter pyloriinfection

“…The amoxicillin resistance rates have been reported to equal 17.2% in Korea, 72.5% in India, 6.8% in China, 4% in Latin America, 2% in the United States, 65.6% in Africa, 11.6% in Asia, and 0.5% in Europe. The tetracycline resistance rate was generally < 1% but equaled 53.8% in India, 6% in Latin America, 3.5% in China, and 2.3% in Israel[21]. The rate of tetracycline resistance did not significantly differ among Europe (2.1%), Asia (2.4%), and United States (2.7%) but was higher in Africa (43.9%).…”

“…Levofloxacin resistance was high in Beijing, China (50.3%)[8], although the levofloxacin resistance rates vary among countries: 14.9% to 38.6% in Japan and 11.9 to 6.8% in Taiwan. The recent resistance patterns revealed rates of 7.7%-18.6% in Europe, 31.3% in the United States, 41.3% in Vietnam, and 15% in Senegal and Latin America[8,21,30]. Primary rifabutin resistance was reported high in China (14.2%)[21] and Bulgaria (12%)[34] but low in Germany (1.4%) and England (6.6%)[30].…”

“…Many factors, such as antibiotic resistance, treatment compliance, dosage administered, duration of therapy, low gastric pH, cytochrome P450 2C19 ( CYP2C19 ) gene polymorphisms, high bacterial load, impaired mucosal immunity and smoking, negatively affect the efficacy of the first-line triple therapy[6,8,20]. The eradication rates of the first-line standard therapy are 55%-57% in Western Europe, 74.5% in China, 84% in South Korea and 87% in Nigeria[8,21]. In cases of high clarithromycin resistance, bismuth-containing quadruple therapy (PPI, bismuth, tetracycline, and amoxicillin) or non-bismuth quadruple (concomitant) therapy has been recommended by more recent Maastricht Guidelines as the first-line therapy[12-14].…”

“…The application of susceptibility testing prior to treatment does not always conclude with successful therapy, but the useless administration of inefficient antimicrobials, adverse drug effects, and the development of antimicrobial resistance can be minimized by pretreatment susceptibility testing[18]. The application of prior antimicrobial susceptibility testing has increased the eradication rates to 97% in Japan and from 84% to 95% in South Korea[21]. …”

Noninvasive molecular analysis ofHelicobacter pylori: Is it time for tailored first-line therapy?

“…Recently, studies about Helicobacter pylori ( H. pylori ) infection worldwide have shown some challenging truths: (1) bacterium spreading is still ongoing[1]; (2) for no other infection such a large number of therapeutic regimens has been proposed[2]; (3) the results are controversial: the same pattern can give exciting or disappointing results depending on geographical areas[3]; and (4) although many experts claim that there are no intractable but only inadequately treated H. pylori strains, currently no study in the world has displayed a 100% therapeutic success rate, i.e ., the ideal therapy does not still exist[4]. …”