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The effectiveness of standard therapy for Helicobacter pylori infection is decreasing in many areas of the world because of increasing antibiotic resistance. Multiple studies have sought to identify alternative treatment approaches to increase both initial and secondary treatment success (JW Gastroenterol Jan 13 2012). Now, investigators have evaluated the effectiveness of novel quadruple therapy regimens in eradicating H. pylori after failure of first-line triple therapy.
Participants included 310 consecutive patients with H. pylori infection who had failed ≥1 course of standard, 7-day triple therapy with a proton-pump inhibitor, amoxicillin, and clarithromycin. Investigators cultured H. pylori from endoscopic biopsies and conducted antibiotic sensitivity testing for multiple antibiotics. Resistance rates to clarithromycin and metronidazole were 94.1% and 67.6%, respectively. Resistance rates to other antibiotics were <6%. Based on antibiotic sensitivity tests, 210 patients received a quadruple regimen comprising 20 mg of rabeprazole and 1 g of amoxicillin three times daily for 10 days and 150 mg of rifabutin and 500 mg of ciprofloxacin twice daily on days 6 to 10 (PARC). Sixty-nine patients with a penicillin allergy received a different quadruple regimen comprising 20 mg of rabeprazole three times daily, 240 mg of bismuth subcitrate four times daily, 150 mg of rifabutin twice daily, and 500 mg of ciprofloxacin twice daily (PBRC), all for 10 days.
H. pylori eradication was successful in 95.2% of patients on PARC and in 94.2% of patients on PBRC. Personalized therapy based on antibiotic sensitivity was given to 31 patients, with an eradication rate of 77.4%. Another 11 patients who failed PARC or PBRC treatment received personalized therapy, with an eradication rate of 45.4%.
The authors conclude that in this cohort of patients who failed ≥1 attempt to eradicate H. pylori, resistance was high to clarithromycin and metronidazole but low to rifampicin and ciprofloxacin, allowing for a high rate of eradication using both the PARC and PBRC quadruple salvage therapies. They also suggest that pretreatment antibiotic sensitivity testing might be helpful in selecting the appropriate salvage therapy.
Tay CY et al. Helicobacter pylori eradication in Western Australia using novel quadruple therapy combinations. Aliment Pharmacol Ther 2012 Dec; 36:1076.
Comment
This sensitivity-based approach to salvage therapy for H. pylori produced high eradication rates in those taking the PARC or PBRC regimens. However, the availability and costs of the drug regimens and sensitivity testing may limit the generalizability of this approach. The most important aspect of H. pylori therapy may be understanding the antibiotic resistance patterns of each specific population and tailoring therapy accordingly. As yet, no standard global solution exists to the problem of increasing antibiotic resistance and decreasing effectiveness of H. pylori therapy.