Helicobacter Pylori Eradication Regimens Research Articles

Study Demonstrating Simple, Cheap and Effective Regimen forHelicobacter Pylori Eradication at a Teaching Hospital of Sindh

Study Demonstrating Simple, Cheap and Effective Regimen forHelicobacter Pylori Eradication at a Teaching Hospital of Sindh

Study Demonstrating Simple, Cheap and Effective Regimen forHelicobacter Pylori Eradication at a Teaching Hospital of Sindh

Study Demonstrating Simple, Cheap and Effective Regimen forHelicobacter Pylori Eradication at a Teaching Hospital of Sindh

Genetic variations of penicillin-binding protein 1A: insights into the current status of amoxicillin-based regimens for Helicobacter pylori eradication in Malaysia.

Introduction. Resistance towards amoxicillin in Helicobacter pylori causes significant therapeutic impasse in healthcare settings worldwide. In Malaysia, the standard H. pylori treatment regimen includes a 14-day course of high-dose proton-pump inhibitor (rabeprazole, 20 mg) with amoxicillin (1000 mg) dual therapy.Hypothesis/Gap Statement. The high eradication rate with amoxicillin-based treatment could be attributed to the primary resistance rates of amoxicillin being relatively low at 0%, however, a low rate of secondary resistance has been documented in Malaysia recently.Aim. This study aims to investigate the amino acid mutations and related genetic variants in PBP1A of H. pylori, correlating with amoxicillin resistance in the Malaysian population.Methodology. The full-length pbp1A gene was amplified via PCR from 50 genomic DNA extracted from gastric biopsy samples of H. pylori-positive treatment-naïve Malaysian patients. The sequences were then compared with reference H. pylori strain ATCC 26695 for mutation and variant detection. A phylogenetic analysis of 50 sequences along with 43 additional sequences from the NCBI database was performed. These additional sequences included both amoxicillin-resistant strains (n=20) and amoxicillin-sensitive strains (n=23).Results. There was a total of 21 variants of amino acids, with three of them located in or near the PBP-motif (SKN402-404). The percentages of these three variants are as follows: K403X, 2%; S405I, 2% and E406K, 16%. Based on the genetic markers identified, the resistance rate for amoxicillin in our sample remained at 0%. The phylogenetic examination suggested that H. pylori might exhibit unique conserved pbp1A sequences within the Malaysian context.Conclusions. Overall, the molecular analysis of PBP1A supported the therapeutic superiority of amoxicillin-based regimens. Therefore, it is crucial to continue monitoring the amoxicillin resistance background of H. pylori with a larger sample size to ensure the sustained effectiveness of amoxicillin-based treatments in Malaysia.

Healthcare costs among patients with newly diagnosed helicobacter pylori infection in the United States: a linked claims-EHR study

AimsThe study objectives were to 1) characterize the cost drivers of patients with Helicobacter pylori (HP) and 2) estimate HP-related cost savings following lab-confirmed HP eradication with US guideline-recommended treatment compared to failed eradication.MethodsWe identified adults newly diagnosed with HP between 1/1/2016–12/31/2019 in the Veradigm Electronic Health Record Database linked to claims data (earliest HP diagnosis = index date). For the overall costs analysis, we required patients to have data available for ≥12 months before and after the index date. Then, we used multivariable modeling to assess the marginal effects of comorbidities on all cause-healthcare costs in the 12 months following HP diagnosis. For the eradication savings analysis, we identified patients with ≥1 HP eradication regimen, a subsequent HP lab test result, and ≥1 year of data after the test result. Then we used multivariable modeling to estimate HP-related cost while adjusting for eradication status, demographics, post-testing HP-related clinical variables, and the interactions between eradication status and each HP-related clinical variable.ResultsThe overall cost analysis included 60,593 patients with HP (mean age 54.2 years, 65.5% female). Mean (SD) 12-month unadjusted all-cause costs were $23,693 ($78,089). Rare comorbidities demonstrated the highest marginal effect. The marginal effects of gastric cancer and PUD were $15,705 and $7,323, respectively. In the eradication savings analysis, 1,835 (80.0%) of the 2295 patients had lab test-confirmed HP eradication. Compared to failed eradication, there were significant one-year cost savings among patients with successful HP eradication and select conditions: $1,770 for PUD, $518 for atrophic gastritis, $494 for functional dyspepsia, and $352 for gastritis.ConclusionsThe healthcare costs of patients with HP are partially confounded by their burden of high-cost comorbidities. In the subset of patients with available results, confirmed vs. failed eradication of HP was associated with short-term cost offsets among those with specific to HP-related sequelae.

Efficacy analysis of empirical bismuth quadruple therapy, high-dose dual therapy, and resistance gene-based triple therapy as a first-line Helicobacter pylori eradication regimen - An open-label, randomized trial.

This research aimed to evaluate the eradication efficacy, safety, and gastrointestinal symptom relief rates of empirical bismuth quadruple therapy, high-dose dual therapy, and resistance gene-based triple therapy in primary eradication patients in Yangzhou, China. It also investigated the possible factors influencing the success of different Helicobacter pylori eradication regimens. A single-center, prospective, open-label, randomized controlled study was performed from December 2020 and October 2021, in which 255 patients with H. pylori infection were assigned in a 1:1:1 ratio to the three different groups. Our results showed that high-dose dual therapy (91.0%, 71/78) and resistance gene-based triple therapy (94.9%, 75/79) achieved eradication rates and compliance equivalent to those of empirical bismuth quadruple therapy (85.3%, 64/75) in the per-protocol analysis, while high-dose dual therapy had lower rates of adverse events (11.5%, 9/78, P < 0.05), fewer side effects, and greater safety. Most patients' gastrointestinal discomfort symptoms improved after eradication of H. pylori. Poor compliance (P < 0.05) and antibiotic resistance (P < 0.05) were risk factors for the efficacy of H. pylori eradication. Therefore, the appropriate regimen can be individualized for eradication therapy in clinical practice according to the patient's resistance and tolerance to the drug.

The benefit of the bismuth add-on to the 2-week clarithromycin-based triple regimen for Helicobacter pylori eradication: a propensity score-matched retrospective study

BackgroundBismuth salt is bacteriostatic and bactericidal against Helicobacter pylori (H. pylori). Little is known about the benefit of bismuth itself. Recently in Korea, government regulation changed to allow bismuth add-on to conventional triple eradication regimens. Study aimed the additional benefit of the bismuth add-on to the 2-week clarithromycin-based triple regimen for H. pylori eradication.MethodsA single-centered retrospective review of electronic medical records was conducted in Seoul, Korea. Treatment-naïve H. pylori infected subjects treated with the clarithromycin-based triple regimen were consecutively enrolled. After propensity score matching, 118 subjects who were treated with rabeprazole 20 mg, amoxicillin 1 g, and clarithromycin 500 mg twice daily for 14 days (PAC) and matched 118 subjects with PAC plus bismuth subcitrate potassium 300 mg twice daily for 14 days (PACB) were included in the final analysis. The primary endpoint was the eradication success rates in each group.Article title: Kindly check and confirm the edit made in the article title.Yes, I agree with the article title. ResultsThe eradication success rates were 91.5% (86.4–96.6%) for PACB regimen and 81.4% (74.2–88.5%) for PAC in the intention-to-treat analysis, and 97.3% (94.2–100%) for PACB and 88.1% (81.9–94.3%) for PAC in the per-protocol analysis. The relative risk of eradication failure for PACB over PAC was calculated as 0.184 (0.0492–0688, p value = 0.005) in multiple regression logistic analysis. Compliance and adverse event incidence were not different between the two groups.Author names: Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: [Da Wit], Last name: [Shin]. Author 2 Given name: [Dae Young], Last name: [Cheung]. Author 3 Given name: [Ji Hee], Last name: [Song]. Author 4 Given name: [Fan Hee], Last name: [Lee]. Author 5 Given name: [Jin Il], Last name: [Kim]. Yes. I found the names presented are accurate and in the correct sequence. Author 1 Given name: [Da Wit], Last name: [Shin].Author 2 Given name: [Dae Young], Last name: [Cheung].Author 3 Given name: [Ji Hee], Last name: [Song].Author 6 Given name: [Han Hee], Last name: [Lee].Author 7 Given name: [Jin Il], Last name: [Kim].ConclusionThe bismuth add-on to the 2-week clarithromycin-based triple regimen increased the eradication success rate.

Diagnosis and treatment patterns among patients with newly diagnosed Helicobacter pylori infection in the United States 2016–2019

Approximately 36% of the United States (US) population is infected with Helicobacter pylori (HP), a known major risk factor for peptic ulcer disease and gastric cancer. HP eradication reduces the rate of complications; however, the benefits are undermined by rising rates of HP eradication treatment failure. This real-world observational cohort analysis aims to describe HP diagnostic and treatment patterns among insured patients in the US. Using diagnoses, lab results, and treatment patterns, we identified adults (18+) with new diagnoses of HP in the Veradigm Health Insights EHR Database linked to Komodo claims data (1/1/2016–12/31/2019). Patients were required to have ≥ 12 months of data pre-/post-index. We captured patient characteristics, HP-related diagnostic testing, and the use of US guideline-recommended HP eradication regimens. HP eradication rates following first-line eradication treatment were measured among patients with available lab results. Overall, 31.8% of the 60,593 included patients did not receive guideline-recommended treatment. Among the 68.2% (41,340) with first-line treatment, 80.2% received clarithromycin-based triple therapy, and 6.6% received bismuth quadruple therapy. Of the 4569 patients with a repeated course of eradication therapy, 53.4% received the same regimen as their first-line, the majority (90.7%) of whom received two rounds of clarithromycin-based triple therapy. Among the 2455 patients with results of HP non-serology testing following first-line treatment, the 180-day eradication rate was 80.2% overall, with differences based on treatments and demographics. This study highlights gaps between guideline-recommended HP management and real-world patterns, underscoring the need to improve HP testing, treatment, and follow-up practices.

Clarithromycin-based Helicobacter pylori eradication therapy is not associated with higher treatment failure compared with non-clarithromycin-based regimens in a tertiary referral hospital in Switzerland

Due to increasing antibiotic resistance, various Helicobacter pylori eradication regimens other than clarithromycin-based therapies have been proposed. However, detailed data on which therapies were employed and their eradication success is lacking. The purpose of this study was to analyse the response rates of different eradication therapy schemes. In this retrospective cohort study, we analysed data of 1721 patients and included 608 patients undergoing H. pylori eradication therapy at the Department of Gastroenterology at the University Hospital Zurich between 2004 and 2018. The primary endpoint was the success rates of clarithromycin- and non-clarithromycin-containing H. pylori eradication regimens. We furthermore analysed factors with potential impact on the outcome of H. pylori eradication therapies, such as demographics, and smoking and social status. The most common therapy scheme (71% of all cases) was proton pump inhibitor (PPI)-amoxicillin-metronidazole, followed by PPI-amoxicillin-clarithromycin (21%) and PPI-metronidazole-clarithromycin (6%). There was no difference between the H. pylori eradication success of clarithromycin vs non-clarithromycin-containing therapies (71% vs 71%, p = 0.764). Despite increasing clarithromycin resistance globally, there was no difference in the eradication success of clarithromycin- and non-clarithromycin-containing therapy regimens in Switzerland. As varying triple therapies do not increase eradication rates in real-world settings, other primary therapy options such as quadruple therapies should be explored.

Second-line levofloxacin-based quadruple therapy versus bismuth-based quadruple therapy for Helicobacter pylori eradication and long-term changes to the gut microbiota and antibiotic resistome: a multicentre, open-label, randomised controlled trial

Levofloxacin-based therapy or bismuth-based quadruple therapy are the recommended second-line regimens for Helicobacter pylori eradication after failure of clarithromycin-based therapy. However, resistance to levofloxacin has increased in the past decade. Furthermore, little is known about the long-term effects of H pylori eradication on the antibiotic resistome. In this study, we compared these second-line eradication therapies for efficacy, tolerability, and short-term and long-term effects on the gut microbiota, antibiotic resistome, and metabolic parameters. We did a multicentre, open-label, parallel group, randomised controlled trial at eight hospitals in Taiwan. Adult patients (age ≥20 years) with persistent H pylori infection after first-line clarithromycin-based therapy were randomly assigned (1:1, permuted block sizes of four) to receive levofloxacin-based sequential quadruple therapy for 14 days (EAML14; esomeprazole 40 mg and amoxicillin 1 g for 7 days, followed by esomeprazole 40 mg, metronidazole 500 mg, and levofloxacin 250 mg for 7 days, all twice-daily) or bismuth-based quadruple therapy for 10 days (BQ10; esomeprazole 40 mg twice daily, bismuth tripotassium dicitrate 300 mg four times a day, tetracycline 500 mg four times a day, and metronidazole 500 mg three times a day). All investigators were masked to the randomisation sequence. The primary endpoint was H pylori eradication rate measured by 13C urea breath test 6 weeks after second-line treatment according to both intention-to-treat (ITT) and per-protocol analysis. The microbiota composition and antibiotic resistome of faecal samples collected at baseline (before treatment) and at 2 weeks, 8 weeks, and 1 year after eradication therapy was profiled by shotgun metagenomic sequencing and 16S rRNA gene sequencing. The frequency of adverse effects and changes in the gut microbiota and antibiotic resistome were assessed in all participants with available data. The trial is complete and registered with ClinicalTrails.gov, NCT03148366. Between Feb 25, 2015, and Dec 11, 2020, 560 patients were randomly assigned to receive EAML14 or BQ10 (n=280 per group; 261 [47%] men and 299 [53%] women). Mean age was 55·9 years (SD 12·7) in the EAML14 group and 54·9 years (12·3) in the BQ10 group. Eradication of H pylori was achieved in 246 (88%) of 280 participants in the EAML14 group and 245 (88%) of 280 in the BQ10 group according to ITT analysis (risk difference -0·4%, 95% CI -5·8 to 5·1; p=0·90). In the per-protocol analysis, 246 (90%) of 273 participants in the EAML14 group and 245 (93%) of 264 participants in the BQ10 group achieved H pylori eradication (risk difference 2·7%, 95% CI -0·2 to 7·4; p=0·27). Transient perturbation of faecal microbiota diversity at week 2 was largely restored to basal state 1 year after EAML14 or BQ10. Diversity recovery was slower with BQ10, and recovery in species abundance was partial after both therapies. On shotgun sequencing, we observed significant increases in total resistome after EAML14 (p=0·0002) and BQ10 (p=4·3 × 10-10) at week 2, which were restored to pretreatment level by week 8. The resistance rates of Escherichia coli and Klebsiella pneumonia to levofloxacin, ciprofloxacin, ampicillin (ampicillin-sulbactam for K pneumonia), and various cephalosporins were significantly increased in the EAML14 group compared with in the BQ10 group at week 2, which were restored to pretreatment levels and showed no significant differences at week 8 and 1 year. The frequency of any adverse effects was significantly higher after BQ10 therapy (211 [77%] of 273 participants) than after EAML14 therapy (134 [48%] of 277; p<0·0001). We found no evidence of superiority between levofloxacin-based quadruple therapy and bismuth-based quadruple therapy in the second-line treatment of H pylori infection. The transient increase in the antibiotic resistome and perturbation of faecal microbiota diversity were largely restored to pretreatment state from 2 months to 1 year after eradication therapy. The Ministry of Science and Technology of Taiwan, the Ministry of Health and Welfare of Taiwan, National Taiwan University Hospital, Taipei Veteran General Hospital, and the Australian Federal Government through the St George and Sutherland Medical Research Foundation. For the Chinese translation of the abstract see Supplementary Materials section.

Bismuth, esomeprazole, metronidazole and amoxicillin or tetracycline as a first-line regimen for Helicobacter pylori eradication: A randomized controlled trial.

Due to general unavailability and common side effects of tetracycline, the clinical application of bismuth quadruple therapy (BQT) is greatly limited. Whether amoxicillin can replace tetracycline in BQT remains unknown. This study aimed to compare the eradication rate, safety and compliance between amoxicillin-containing and tetracycline-containing BQT as a first-line regimen for Helicobacter pylori eradication. This randomized trial was conducted on 404 naïve patients for H. pylori eradication. The participants were randomly assigned to 14-day amoxicillin-containing (bismuth potassium citrate 110 mg four times/day, esomeprazole 20 mg twice daily, metronidazole 400 mg four times/day and amoxicillin 500 mg four times/day) and tetracycline-containing (tetracycline 500 mg four times/day and the other three drugs used as above) BQT. Safety and compliance were assessed within 3 days after eradication. Urea breath test was performed 4-8 weeks after eradication to evaluate outcome. As for the eradication rates of amoxicillin-containing and tetracycline-containing BQT, the results of both intention-to-treat and per-protocol analyses showed that the difference rate of the lower limit of 95% confidence interval was above -10.0% (intention-to-treat analysis: 81.7% vs. 83.2%, with a rate difference of -1.5% [-6.3% to 9.3%]; per-protocol analysis: 89.0% vs. 91.6%, -2.6% [-4.1% to 9.3%]). The incidence of adverse events in amoxicillin-containing BQT was significantly lower than tetracycline-containing BQT (29.5% vs. 39.7%). Both groups achieved relatively good compliance (92.0% vs. 89.9%). The eradication efficacy of amoxicillin-containing BQT was non-inferior to tetracycline-containing BQT as a first-line regimen for H. pylori eradication with better safety and similar compliance.

S3741 An Interesting Case of a Double Pylorus

Introduction: Double pylorus also termed double-channel pylorus is an endoscopic finding that refers to the presence of a double connection between the gastric antrum and the duodenal bulb. This connection is typically established through the presence of a gastroduodenal fistula. Despite that double pylorus is reported in the literature, its incidence is extremely low and accounts for less than 0.4% of upper endoscopic findings. Herein we report the case of 74 year-old Albanian man who was found to have a double pylorus in the setting of peptic ulcer disease. Case Description/Methods: A 74 year-old man with history of hypertension presented to the emergency room with a few week history of epigastric pain, nausea and vomiting. He denied NSAIDs intake. Vital signs were within normal range. Physical examination revealed epigastric tenderness. Laboratory tests were unremarkable. Abdominal CT scan showed inflammatory changes of the gastric antrum and proximal duodenum (panel A). Findings on upper endoscopy included erythema and edema of the gastric wall, a 7 mm cratered duodenal bulb ulcer in addition to a gastroduodenal fistula that connected the gastric antrum to the proximal duodenum consistent with a double pylorus (panel B). Routine staining of gastric biopsies identified Helicobacter Pylori (HP) organisms. The patient received high dose proton pump inhibitors and Helicobacter Pylori eradication regimen. His symptoms significantly improved and was successfully discharged home after few days of treatment initiation. He was advised to avoid Non-steroidal anti-inflammatory drugs and was scheduled for an outpatient follow-up to document eradication of HP. Discussion: Double pylorus was first described in 1969. It is twice as common in men compared to women. It can be congenital or acquired. Congenital cases are associated with gastric duplication, heterotrophic pancreatic tissue and pancreas divisum. Acquired double pylorus is usually secondary to systemic diseases, gastric malignancy, drugs or Helicobacter Pylori infection that lead to the formation of a fistulous tract between the gastric antrum and the proximal duodenum. Double pylorus can be asymptomatic or manifest as gastrointestinal bleeding or abdominal pain. Treatment includes acid suppression via proton pump inhibitors or H2-Receptor antagonists. Refractory and complicated cases require advanced endoscopic or surgical interventions.Figure 1.: Panel A: CT scan of the abdomen showing inflammatory changes of the gastric antrum and proximal duodenum; Panel B: Upper endoscopy showing a gastroduodenal fistula connecting the gastric antrum to the proximal duodenum consistent with a double pylorus.

Effectiveness and Safety of Rifaximin-Containing Regimens for Helicobacter pylori Eradication: Systematic Review - Are They Potential Eradication Regimens?

BackgroundRifaximin, a rifamycin antibiotic, is widely used to treat infectious diarrhea but not commonly used in H. pylori eradication. With its potential advantages of the agent, some studies were conducted on this topic. The aim of this study is to assess effectiveness and safety of rifaximin-containing regimens and to evaluate whether they are alternative choices for H. pylori eradication.MethodsScientific databases including PubMed, EMbase and Cochrane Library were used to identify clinical trials on rifaximin-containing regimens published from January 2000 to October 2021. Review Manager 5.4 and STATA12 were adopted for the systematic review.ResultsIn this study, totally 1025 patients were included from 3 randomized controlled and 9 single-arm studies. It showed that the differences in effectiveness and safety between rifaximin-containing and first-line regimens were not statistically significant in randomized controlled trials. However, the results of the single-arm trials indicated that the eradication and adverse drug reaction rate varied suggesting data instability (r=38.1%-85.4%, rADR 0.00–67.5% by ITT analysis). Among them, the eradication rate of pediatric patients (r=85.4% by ITT analysis) was higher than that of adult patients (r=38.1–74.5% by ITT analysis). Meanwhile, in all adult subgroups (triple or quadruple, with or without amoxicillin, different duration and rifaximin dose), the results did not show sufficient effectiveness as all the eradication rates did not meet the minimum ideal or ideal target.ConclusionTaken together, rifaximin-containing regimens should not be recommended for H. pylori eradication as they cannot achieve the eradication rate desired.

Eradication of Helicobacter pylori: what determines the effectiveness antihelicobacter pharmacotherapy (according to the results of the analysis of urease breath tests performed in 2006-2019 in Vinnytsia region)

Annotation. One of the global challenges of modern gastroenterology, which prevents the provision of acceptable levels of eradication of Helicobacter pylori, is the problem of increasing resistance of Helicobacter pylori to previously effective antibiotic regimens. The aim of the study – evaluate the effectiveness of Helicobacter pylori eradication depending on the chosen antihelicobacter pharmacotherapy regimen and the used proton pump inhibitors. We analyzed the results of 906 urea breath tests, which were conducted to monitor the effectiveness of antihelicobacter therapy for the period from 2006 to 2019. To analyze the results obtained, the examined patients were divided into groups depending on the scheme of Helicobacter pylori eradication of and the proton pump inhibitors used. Doses, multiplicity and duration of Helicobacter pylori eradication regimens met the requirements of the then valid Maastricht Consensus. We used Student's t-test for relative values to assess significant differences between the study groups. During the period 2006-2019, there is a significant level (32.1% of all tests conducted to control antihelicobacter pharmacotherapy) of the Helicobacter pylori eradication schemes use by doctors in Vinnytsia region that do not meet the criteria of the Maastricht Consensus and are characterized by low efficiency (eradication level of Helicobacter pylori 65 %), however, since 2016 there has been a significant (p &lt;0.01) decrease in the following appointments: 2016 – 29.4%, 2017 – 22.7%, 2018 – 14.8%, 2019 – 8.2%, respectively. Among the schemes of antihelicobacter pharmacotherapy (2006-2019), doctors of Vinnytsia region prefer the appointment of PPI + Cl + Am and PPI + Cl + Am + B (61.6% and 20.7% among all tests performed to control the eradication of H.p. respectively) with a tendency to increase the purpose of the PPI + Cl + Am + B scheme since 2016: 2016 – 22.7%, 2017 – 22.7%, 2018 – 34.1%, 2019 – 29.2%. These schemes showed the highest efficiency during the entire observation period: PPI + Cl + Am – 81.6%, PPI + Cl + Am + B - 87%. The choice of omeprazole in the eradication scheme of Helicobacter pylori based on PPI + Cl + Am + B leads to significantly (p &lt;0.01) worse eradication results compared to pantoprazole, lansoprazole, rabeprazole and esomeprazole: 68% vs. 87.1%, 100%, 100% and 88.9% respectively.

A Comparison Between 10-Day and 12-Day Concomitant Regimens for Helicobacter Pylori Eradication

H. pylori (Helicobacter pylori) is the most prevalent infection worldwide which leads to gastric ulcer and cancer. In our research work, patients infected with H. pylori were given concomitant treatment for 10 and 12 days and compared to find the efficiency of treatment. Objective: The objective of this study is to find a cost-effective therapeutic method for the treatment of H. pylori. Previous 14-day treatment was effective but it was expensive due to the high cost of antibiotics as well as the negative side effects of the treatment, so an alternative method is required to reduce the need of costly antibiotics and the duration of treatment. Study design: It is a comparative study with statistical approach, conducted in the medicine department of Sialkot Medical College, Sialkot for the duration of six months from June 2021 to November 2021. Methods: For this study, 196 patients with gastric ulcers were selected and confirmed H. pylori positive by a diagnostic test. These patients randomly distributed into two groups and given treatment for 10 and 12 days respectively. UBT was used to find either H. pylori is eradicated or not. “Registry of clinical trials” registered this experiment. Results: For this research work, 196 patients were selected, after the concomitant therapy eradication rate was analyzed that comes out as 83 % (CI 95.0%: 76-90) and 88 % (CI 95%: 82-94) for 10 and 12 day therapy, respectively (p = 0.23). Then, prediction of per-protocol eradication was done and it came out as 85% (CI 95%: 79-92) and 92% (CI 95%: 87-97), respectively (p = 0.18). When side effects were compared between two groups, no statistical difference exist between two (3.5% vs. 8.0%; p = 0.419). Conclusion: All the results suggested that the concomitant therapy that was given for 12 days was more effective for treatment and per-protocol assessment. For the reduction of the cost of antibiotics, 12 day treatment is more effective for treatment as well as the replacement of 14 day treatment that was suggested by international rules. Keywords: Helicobacter pylori, gastric ulcer, concomitant therapy, treatment efficacy, H. pylori eradication.

Effectiveness and safety of vonoprazan-based regimen for Helicobacter pylori eradication: A meta-analysis of randomized clinical trials.

The Helicobacter pylori (H.pylori) eradication rate of proton pump inhibitor (PPI)-based regimen remains decreasing. Vonoprazan (VPZ), a stronger and longer-lasting acid blocker, has been proposed to treatment of H.pylori infection. However, previous reviews did not have a pre-established study protocol and did not conduct a comprehensive search of the database, so the results obtained were not robust. We aimed to perform a meta-analysis to assess the effectiveness and safety of VPZ-based regimens for treatment of H.pylori infection in comparison with other regimens. We conducted a systematic literature search on PubMed, Embase, Cochrane Library, Web of Science, ClinicalTrials and ChiCTR Register. Randomized clinical trials comparing VPZ-based regimens with similar eradication regimens without VPZ in the treatment of H.pylori infection were included. Eradication rate, compliance of the patients and side effects were specified as the primary outcomes. RevMan 5.4software was used to analyze the RCTs and provide pooled risk ratio (RR) with 95% confidence intervals (CI). Systematic searches, study selection, data extraction, risk of bias assessment and statistical analysis were performed by two independent researchers according to the predesigned criteria on the PROSPERO. A total of 8 RCTs with 2012 patients qualified for evaluation. The results showed that the eradication rate of VPZ-containing regimens was significantly superior to PPI-containing regimens for both intention-to-treat (RR, 1.14; 95% CI: 1.06-1.23; p=0.0006) and per-protocol analyses (RR, 1.12; 95% CI: 1.04-1.20; p=0.003). Subgroup analysis based on treatment regimens, eradication experience and clarithromycin resistance, as well as sensitivity analysis further confirmed this finding. In addition, there was no significant difference in compliance (RR, 1.02; 95% CI: 0.98-0.1.05; p=0.35) and the frequency of adverse events (RR, 0.84; 95% CI: 0.70-1.00; p=0.05) between the regimens. Compared with PPI-based regimens, the VPZ-containing regimens showed a comparable or even superior eradication rate of H.pylori in terms of overall comparison and comparison of different treatment regimens, eradication experience and clarithromycin resistance. In addition, VPZ-based regimens have better tolerability and fewer adverse events. More future studies are needed to evaluate the impact of some differences in patient characteristics. PROSPERO CRD42021229598.

Bismuth‐based quadruple therapy vs concomitant therapy for Helicobacter pylori eradication—a real‐world experience

Background and Aims Both bismuth-based quadruple therapy (BQT) and concomitant therapy (CCT) are first-line regimens for Helicobacter pylori eradication. We compared the efficacy and adverse effects of both regimens in day-to-day clinical practice. Methods Adult patients with biopsy-proven H. pylori infection were included. Drug therapy was based on patient and physician preference. Both BQT and CCT regimens were given for 14 days. Efficacy was assessed using a stool antigen for H. pylori 4 weeks after treatment. Results One hundred and twenty-nine consecutive patients were analysed, and the demographic characteristics of the two groups were similar. Treatment compliance was comparable in both regimens (P = 0.074), and 12/81 (14.8%) and 3/48 (12.5%) defaulted in BQT and CCT groups, respectively. 64.2% and 48% of patients reported some adverse effect in BQT and CCT groups (P = 0.10). Predominant adverse effects reported were nausea (41.9% vs 25%), black stools (29.6% vs 2%), vomiting (24.7% vs 6.25%) and loose stools (9.8% vs 20.8%) in BQT and CCT groups. Treatment efficacy of BQT and CCT regimen by intention-to-treat analysis was 87.7% (n = 71/81) and 79.2% (n = 38/48) (P = 0.321) and by per-protocol was 89.9% (n = 62/69) and 82.2% (n = 37/45) (P = 0.37). Conclusion Treatment efficacy with BQT is equivalent to CCT for H. pylori eradication. Both regimens have similar compliance rates, adverse events and affordability. With rising antibiotic resistance, BQT should be considered a better first-line option for H. pylori eradication.

Helicobacter pylori eradication following first-line treatment failure in Europe: What, how and when chose among different standard regimens? A systematic review

Cure rate following standard first-line regimens for Helicobacter pylori eradication is decreasing so several patients require two or more treatments. Antibiotic susceptibility-based therapy, advised in current guidelines, is largely impracticable in clinical practice. Some 'standard' regimens (triple therapies based on either levofloxacin or rifabutin, bismuth-based quadruple therapies, sequential, concomitant and hybrid therapies) were empirically used as rescue therapies. We performed a systematic review on recent studies carried out in European countries dealing with these regimens. A total of 24 studies, with 3804 patients, were identified. As second-line therapy, Pylera (89.2%) and sequential therapy (92.5%) achieved significantly higher cure rates as compared to all the other regimens. As third-line therapy, levofloxacin-based therapy (84.1%) and Pylera (83.6%) achieved similarly high cure rates, whereas standard, bismuth-based quadruple therapy (64.1%) achieved the lowest. As a rescue therapy, the success rate was close to 75% following all therapies used, with data on rifabutin-based regimen consolidated in the larger sample size. Overall, levofloxacin-amoxicillin triple therapy achieved higher eradication rates when the 14- rather than 10-day regimen was used (87.1 vs. 72.2%; P = 0.003). Among bismuth-based therapies, Pylera achieved a significantly higher eradication rate than standard quadruple therapy (88 vs. 67%; P < 0.0001). These data suggest that a wise 'therapeutic package' following first-line therapy could be Pylera, levofloxacin- and rifabutin-based therapy, as long as Pylera therapy was not used as a first-line regimen and levofloxacin-based regimen was administered for 14 days.

Efficacy of bismuth added to standard triple therapy as the first-line eradication regimen for Helicobacter pylori infection.

Addressing the increasing antibiotic resistance, including clarithromycin resistance, which affects Helicobacter pylori eradication therapy, is a challenge for clinicians. The objective of this study was to determine the efficacy of bismuth added to standard triple therapy as a first-line treatment regimen for Helicobacter pylori infection. The secondary outcome was the treatment efficacy for clarithromycin-resistant strains. A prospective study was undertaken from January to December 2019. A total of 107 patients with Helicobacter pylori infection were enrolled and received Helicobacter pylori eradication therapy with bismuth added to standard triple therapy for 14days. We also evaluated the clarithromycin resistance rate by dual-priming oligonucleotide-based multiplex PCR and treatment efficacy. A total of 104 patients completed standard triple therapy with bismuth added for Helicobacter pylori eradication. The eradication rates in the intention to treat and per-protocol analyses were 87.9% and 90.4%, respectively. The frequency of clarithromycin resistance was 33.6% (35/104), and the eradication rate was 77.1% in resistant strains (27/35). Bismuth added to standard triple therapy could be acceptable as a first-line treatment regimen for Helicobacter pylori eradication in patients with clarithromycin-resistant strains. In particular, in areas with high clarithromycin tolerance, it is advisable to consider bismuth add-on therapy as the first-line treatment regimen.

Comparison of the Different Protocols for the Eradication of Pediatric Helicobacter Pylori Infection in Iran

Background Helicobacter pylori has become very important recently due to infecting around 50% of the population worldwide. This infection can cause peptic ulcer disease and gastric cancer. This study aimed to evaluate the efficacy of common triple treatment, sequential treatment, and other regimens for Helicobacter pylori eradication in children. Materials and Methods: In this retrospective cohort study, 40 children who were diagnosed with Helicobacter pylori infection by endoscopic and pathologic features in the Children’s Medical Center of Tehran, Iran, in 2018 were included. The questionnaire was completed by telephone interview. Types of protocols include triple therapy (proton pump inhibitors with clarithromycin and amoxicillin or metronidazole for 2 weeks), sequential therapy (proton pump inhibitors with amoxicillin for 5 days followed by proton pump inhibitors with clarithromycin and metronidazole for 5 days), and other treatments (every protocol except triple and sequential regimens). At the end, we compared the efficacy of the different protocols for eradicating this infection by urea breath test or stool antigen test 8 weeks after therapy. Results: The age of patients with and without successful eradication was 8.12 and 7.8 years, respectively (p=0.8). There was no significant difference between both sexes (p=0.999) in the frequencies of eradication. The eradication rate of Helicobacter pylori was 95.5% in sequential therapy, 100% in conventional triple therapy, and 87.5%in other regimens. There was no significant difference between different protocols (p=0.422). Conclusion Determining first-line treatment for eradicating Helicobacter pylori infection is important to increase treatment success and reduce rate of secondary antimicrobial resistance. Our study showed that sequential treatment is as effective as conventional treatment in eradication of this infection in children.

Comparison of Furazolidone Versus Clarithromycin for Eradication of Helicobacter Pylori Infection: A ‎Randomized Multicenter Clinical Trial ‎

Background and study aims‎: to evaluate efficacy of Furazolidone versus clarithromycin in quadruple therapy for eradication of ‎Helicobacter Pylori (HP) infection‎ ‎‎. Patients and Method: During a period of six months, all of the cases with HP infection in 3 referral tertiary centers ‎included. The participants randomly allocate to receive either clarithromycin or Furazolidone base ‎quadruple regimen. For all of the participants pantoprazole continued for 4 more weeks and after 1 ‎to 2 weeks of off therapy, they underwent Urea Breath Test to prove eradication‎‎. Results: Overall 386 patients included (165 male (42%), average age 44.2y). They diagnosed as non-ulcer ‎dyspepsia (311 cases), peptic ulcer disease (34 cases) and intestinal metaplasia (45 cases). The ‎participants randomly allocated to groups A & B to receive either clarithromycin or Furazolidone.‎ In groups A and B, 80.9% & 82.1% of participants achieved eradication respectively (P = 0.819). ‎During study, there was not any major complication but 3.1% of participants in each group ‎reported minor side effects including bitter taste, Gastrointestinal (GI) upset, headache and or ‎vertigo. In sub group analysis, the eradication rate of clarithromycin among patients with non-ulcer ‎dyspepsia, peptic ulcer disease (PUD) and intestinal metaplasia were 80%, 100% & 55.6% ‎respectively. These figures in group B (Furazolidone) were 80.7%, 100% & 85.7% respectively ‎‎(P= 0.906, 0 & 0.162). Overall, there was no significant difference in success rate between ‎clarithromycin and Furazolidone but in cases with intestinal metaplasia, the positive results with ‎Furazolidone was more (85.7% vs. 55.6%)‎‎. Conclusion: In areas with high rate of resistance to clarithromycin, Furazolidone could be a potential candidate ‎in HP eradication regimen and in cases with intestinal metaplasia; Furazolidone could be even ‎more efficient than clarithromycin‎‎.