1237 Efficacy and Safety of Nitazoxanide-Based Regimen for the Eradication of Helicobacter pylori Infection: A Systematic Review and Meta-Analysis

Abstract

INTRODUCTION: Helicobacter pylori (HP) is the most common cause of gastritis worldwide. Clarithromycin-based triple therapy and bismuth-based quadruple therapy are among recommended first-line treatment regimens, but may fail in around 30% of patients. Resistance of HP to clarithromycin and metronidazole is also a growing concern. Therefore, there is a need for newer, reliable eradication regimens for HP. Nitazoxanide (NTZX), a bactericidal thiazolide antibiotic, has been effective in HP infection. We conducted a systematic review and meta-analysis to evaluate the efficacy of NTZX-based regimens for the eradication of HP. METHODS: We searched several databases from inception to April 2019 to identify studies that used nitazoxanide as part of an HP treatment regimen. We only included patients who completed the full length of therapy and were tested for eradication on follow up. Our primary outcome was the pooled HP eradication rate. We also performed a subgroup analysis to evaluate NTZX-based regimens in patients who had failed prior treatment. Pooled eradication rates and 95% confidence intervals (CIs) were initially calculated as per protocol analysis from the included studies. Publication bias was evaluated by Egger's test. RESULTS: Twelve studies including 978 patients met our inclusion criteria and were included in the meta-analysis. There were 4 randomized controlled trials, 7 prospective cohort studies and 1 retrospective cohort study. 7 studies were of good quality and 5 studies were of fair quality. HP eradication was successful in 826; (pooled eradication rate = 83%; 95% CI 76-90%) without significant heterogeneity (P = 0.17). In a subgroup analysis including 230 patients who had failed other prior regimens, the pooled eradication rate was 80% (95% CI 66-94%) without significant heterogeneity (P = 0.39). No serious adverse events were reported. In a subgroup analysis, the highest eradication rates were with levofloxacin, doxycycline, NTZX and a proton pump inhibitor; pooled eradication rate = 92% (81 -100%). There was no publication bias as evaluated by Egger's test [P = 0.94]. CONCLUSION: NTZX-based regimens appear safe and effective first-line for HP eradication and are also successful as salvage therapy in patients who had failed prior treatments. Larger randomized controlled trials are required to determine the most effective NTZX-based regimen and the optimum duration of therapy for this increasingly multi drug-resistant infection.