Update on the first-line treatment of Helicobacter pylori infection in areas with high and low clarithromycin resistances

Abstract

Current international consensuses on Helicobacter pylori eradication therapy recommend that only regimens that reliably produce eradication rates of ⩾90% should be used for empirical treatment. The Real-world Practice & Expectation of Asia-Pacific Physicians and Patients in Helicobacter Pylori Eradication Survey also showed that the accepted minimal eradication rate in H. pylori-infected patients was 91%. According to efficacy prediction model, the per-protocol eradication rates of 7-day and 14-day standard triple therapies fall below 90% when clarithromycin resistance rate ⩾5%. Several strategies including bismuth-containing, non-bismuth-containing quadruple therapies (including sequential, concomitant, hybrid and reverse hybrid therapies), high-dose dual therapy and vonoprazan-based triple therapy have been proposed to increase the eradication rate of H. pylori infection. According to efficacy prediction model, the eradication rate of 14-day concomitant therapy, 14-day hybrid therapy and 7-day vonoprazan-based triple therapy is less than 90% if the frequency of clarithromycin-resistant strains is higher than 90%, 58% and 23%, respectively. To meet the recommendation of the consensus report and patients’ expectation, local surveillance networks for resistance of H. pylori to clarithromycin are required to select appropriate eradication regimens in each geographic region. In areas with low (<5%) clarithromycin resistance (e.g. Sweden, Philippine, Myanmar and Bhutan), 7-day and 14-day standard triple therapies can be adopted for the first-line treatment of H. pylori infection with eradication rates of ⩾90%. In areas with high (⩾5%) clarithromycin resistance (most other countries worldwide) or unknown clarithromycin resistance, 14-day hybrid, 14-day reverse hybrid, 14-day concomitant and 10- to 14-day bismuth quadruple therapy can be used to treat H. pylori infection.

Antibiotic resistance in Helicobacter pylori: From potential biomolecular mechanisms to clinical practice

“…However, its resistance rate is continuously increasing in some regions and countries 34 . As further research and development‐related alternative to compensate for the losing efficacy in therapeutic regimens is hard to accomplish quickly, the WHO recommended that cautious application of CLR in regions with a resistance rate of more than 20% is a likely successful approach 35 . Alessia Savoldi et al assessed the CLR‐resistance rate of H. pylori in all WHO regions 36 .…”

Empiric use of standard triple therapy inHelicobacter pylorieradication does not require readjustment in the clarithromycin resistance cut-off point

“…Hsu et al suggest a cutoff for clarithromycin resistance at or below 5 % for the empirical use of PPI-amoxicillin-clarithromycin and base their claim on a recent systematic review 4. However, this review has several relevant limitations:…”

“…Fourth, it remains implausible from studies included in the analysis of Shih et al 4 that patients harbouring clarithromycin-susceptible strains treated with 7-day triple standard therapy had a higher eradication rate (92.5%) than those receiving 14-day triple standard therapy (eradication rate of 90.2%).…”

Cut-off value of clarithromycin resistance in the treatment ofHelicobacter pyloriinfection: how low is low?

“…In the consensus report, clarithromycin triple therapy is recommended as first-line empirical treatment in areas of low clarithromycin resistance, and low clarithromycin resistance is defined as clarithromycin resistance rate <15%. However, a recent systemic review for randomised controlled trials published between 1 January 2011 and 1 January 2022 showed that the per-protocol eradication rates of 14-day clarithromycin triple therapy for clarithromycin-susceptible strains and clarithromycin-resistant H. pylori strains were 90.2% and 46.2%, respectively 3. The corresponding eradication rates of 7-day clarithromycin triple therapy were 92.5% and 42.9%.…”

“…The corresponding eradication rates of 7-day clarithromycin triple therapy were 92.5% and 42.9%. According to efficacy prediction model, per-protocol eradication rates of 7-day and 14-day clarithromycin triple therapies fall below 90% when clarithromycin resistance rate is greater than 5% 3. In fact, all the prospective studies in that systemic review demonstrated that per-protocol eradication rates of 7-day and 14-day clarithromycin triple therapies fell below 90% in areas with clarithromycin resistance between 7% and 14% 4 5.…”