Rescue Therapies for H. pylori Infection in Italy.

Vincenzo De Francesco,Matteo Pavoni,Ilaria Maria Saracino,Angelo Zullo,Luigi Gatta,Giulia Fiorini,Dino Vaira,Raffaele Manta

doi:10.3390/antibiotics10050525

Abstract

Background/Aims: Curing Helicobacter pylori infection remains challenging for clinicians, as no proposed first-line therapy achieves bacterial eradication in all treated patients so that several patients need two or more consecutive treatments. Bacterial culture with antibiotics susceptibility testing is largely unachievable in Italy, and empiric second-line and rescue therapies are generally used. This study aimed to identify what eradication regimens perform better in Italy, following first-line therapy failure. Methods: We performed a literature search on PubMed for studies on standard therapy regimens used as second-line or rescue treatments performed in adult patients. Studies including modified drug combinations were not considered. Both intention-to-treat and per- protocol analyses were computed for each therapy subgroup. Results: Data from 35 studies with a total of 4830 patients were eventually considered. As a second-line therapy, Pylera® (90.6%) and a sequential regimen (89.8%) achieved eradication rates significantly higher than other therapies. For third-line therapy, a levofloxacin-based regimen and Pylera® achieved comparable eradication rates (88.2% vs. 84.7%; p = 0.2). Among therapies used as fourth (or more) attempts, Pylera® and a rifabutin-based therapy achieved 77.4% and 66.4% cure rates, respectively (p = 0.013). A therapy sequence based on the type of first-line therapy used was proposed. Conclusions: Data obtained through our review indicate that standard therapies for H. pylori eradication can be used when following an appropriate sequence, allowing clinicians to improve the cure rate without resorting to bacterial culture.

Highlights

Helicobacter pylori still remains a widely diffuse infection worldwide [1], and it is the main cause of both benign and malignant gastroduodenal diseases, including non-ulcer dyspepsia, peptic ulcers, gastric MALT-lymphoma and carcinoma, as well as interaction with non-steroidal anti-inflammatory drugs in causing gastroduodenal lesions [2,3]
H. pylori eradication following therapy failures remains challenging for clinicians
This largely applies to clarithromycin, levofloxacin and metronidazole; whilst both primary and secondary resistance towards amoxicillin and tetracycline remain very low [49]

Summary

Introduction

Helicobacter pylori still remains a widely diffuse infection worldwide [1], and it is the main cause of both benign and malignant gastroduodenal diseases, including non-ulcer dyspepsia, peptic ulcers, gastric MALT-lymphoma and carcinoma, as well as interaction with non-steroidal anti-inflammatory drugs in causing gastroduodenal lesions [2,3]. H. pylori plays a definite role in some extra-intestinal disorders, such as idiopathic thrombocytopenic purpura and idiopathic iron deficiency anemia [4,5], whilst the association with other diseases (neurological, dermatological, hematologic, ocular, cardiovascular, metabolic, allergic, and hepatobiliary diseases) deserves further investigation [6]. It is well known that H. pylori eradication definitely changes the natural history of peptic ulcer disease, in terms of recurrence and complications. H. pylori eradication is not achieved, since several bacterial and host factors are involved in the therapeutic success, so that an antibiotic combination is required [7].

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