Effectiveness of triple therapy and quadruple therapy for Helicobacter pylori eradication]

BACKGROUND/AIMS: Quadruple therapy can be considered as a first-line therapy in areas where the resistance rate to clarithromycin is high. Comparison study of triple therapy and quadruple therapy for Helicobacter pylori (H. pylori) eradication is still lacking in Korea despite the increasing prevalence of antibiotic resistance. This study was conducted to compare the efficacy of triple and quadruple therapy as a first-line treatment in H. pylori infected patients with peptic ulcer. METHODS: Consecutive 149 cases of peptic ulcer disease associated with H. pylori infection were randomized either to proton pump inhibitor (PPI, bid), amoxicillin (1,000 mg, bid), and clarithromycin (500 mg, bid) (PAC group) or to PPI (bid), bismuth subcitrate (300 mg, qid), metronidazole (500 mg, tid), and tetracycline (500 mg, qid) (PBMT group) eradication treatments for 7 days. Outcome of eradication therapy was assessed by 13C-urea breath test performed 4-6 weeks after eradication. RESULTS: Eradication rates in PAC and PBMT group were 78.7% (59/75) and 71.6% (53/74) by intention to treat analysis, respectively (p=0.424). By per protocol analysis, eradication rates of PAC and PBMT group were 85.5% (59/69) and 85.5% (53/62), respectively (p=1.012). Adverse reactions occurred in 5 (6.6%) and 7 (9.5%) patients in PAC and PBMT group, respectively (p=0.346). CONCLUSIONS: One week-quadruple therapy as a first-line treatment for H. pylori infection does not offer any advantage over PPI-based triple therapy in Korean patients.     

The efficacy of levofloxacin based triple therapy for Helicobacter pylori eradication]

BACKGROUND/AIMS: The failure rates of first and second line therapies of Helicobacter pylori (H. pylori) eradication range from 15 to 20%. This study was aimed to evaluate the efficacy and safety of levofloxacin based triple therapy compared with standard triple or quadruple therapy for H. pylori eradication in Korea. METHODS: We enrolled two hundred and sixty seven patients with presence of H. pylori infection. One hundred and forty-one patients were treated with levofloxacin based triple therapy (LAP; levofloxacin, amoxicillin, proton pump inhibitor; PPI), and 126 patients were treated with standard triple therapy (CAP; clarithromycin, amoxicillin, PPI). We retreated the patients who had failed in H. pylori eradication with standard quadruple second-line therapy (MTPB; metronidazole, tetracycline, PPI, bismuth subcitrate) or levofloxacin based therapy (LAP or LCP; levofloxacin, clarithromycin, PPI). RESULTS: In first line therapy of H. pylori eradication, the eradication rates of levofloxacin based triple therapy and standard triple therapy were 69.8% and 74.0% respectively (p=0.52). In second-line therapy, the eradication rate of levofloxacin based triple therapy and standard quadruple therapy were 62.5% and 40.0% respectively (p=0.34). CONCLUSIONS: Levofloxacin based triple therapy is effective as standard regimen to eradicate H. pylori infection and is useful for an alternative rescue therapy as well.     

序贯疗法和标准三联疗法根除幽门螺杆菌的疗效比较

目的:观察10d序贯疗法治疗幽门螺杆菌(Helicobacter pylori,H.pylori)的疗效及不良反应,与14d三联标准疗法比较H.pylori根除情况及经济学上有无优越性.方法:将103例经胃镜检查确诊为慢性胃炎或消化性溃疡且H.pylori阳性的患者随机分为两组,治疗组(10d序贯疗法)52例,前5d埃索美拉唑、阿莫西林,后5d埃索美拉唑、克拉霉素、替硝唑.对照组(14d标准三联疗法)51例,埃索美拉唑、阿莫西林、克拉霉素14d.所有患者停药4wk后复查13C呼气试验或胃镜检查,判断H.pylori根除情况.结果:治疗组H.pylori根除率为90.4%,与对照组(90.2%)比较无统计学差异(P=1.000);两组不良反应发生率分别为12/52(23.1%)、18/51(35.3%),两组比较无统计学差异(P=0.172);治疗组费用为380.6元,较对照组(677.88元)明显减低.结论:10d序贯疗法的H.pylori根除率不低于标准14d三联疗法,2组不良反应发生率相似,但10d序贯疗法根除H.pylori的效价比更高.     

Efficacy of levofloxacin-based triple therapy as second-line Helicobacter pylori eradication]

BACKGROUND/AIMS: Bismuth-based quadruple therapy for second-line eradication treatment achieves the eradication rate ranging from 70% to 81% due to antimicrobial resistance and poor compliance. The aim of this study was to compare the eradication rate of levofloxacin-based triple therapy with that of bismuth-based quadruple therapy in second-line Helicobacter pylori (H. pylori) eradication therapy. METHODS: Seventy-six outpatients with persistent H. pylori infection after first-line triple therapy were enrolled in this prospective randomized trial. The subjects were randomized to receive levofloxacin 300 mg, amoxicillin 1 g, and pantoprazole 20 mg, given twice daily for 7 days (LAP group), or metronidazole 500 mg twice, tetracycline 500 mg four times, and pantoprazole 20 mg twice, bismuth subcitrate 600 mg twice daily for 7 days (MTPB group). Eradication was confirmed with (13)C-urea breath test or rapid urease test 4 weeks after the cessation of therapy. RESULTS: Among Seventy-six patients initially included, eleven were lost during follow-up. The eradication rates, expressed as intention to treat (ITT) and per protocol (PP) analyses, were 51.6% and 53.3% in the LAP group, and 48.9% and 62.9% in the MTPB group, respectively. There was no significant difference in H. pylori eradication rates between the two groups (p=0.815 by ITT, p=0.437 by PP). LAP regimen was better tolerated than MTPB regimen with lower incidence of side effects (10.0% versus 31.4%, p=0.03). CONCLUSIONS: H. pylori eradication rates of levofloxacin-based triple therapy and bismuth-based quadruple therapy were not significantly different in second-line H. pylori eradication therapy, and low incidence of side effects was observed in levofloxacin-based triple therapy.     

Furazolidone-based triple and quadruple eradication therapy for Helicobacter pylori infection

AIM: To evaluate the efficacy of furazolidone-based triple and quadruple therapy in eradicating Helicobacter pylori (H. pylori) in a multi-center randomized controlled trial.METHODS: A total of 720 H. pylori positive patients with duodenal ulcer disease were enrolled at 10 different hospitals in Jiangxi province in China. The patients were randomly assigned to four treatment groups as follows: patients in Groups 1 and 3 received rabeprazole (10 mg), amoxicillin (1000 mg) and furazolidone (100 mg) twice daily for 7 and 10 d, respectively; patients in Groups 2 and 4 received rabeprazole (10 mg), bismuth (220 mg), amoxicillin (1000 mg) and furazolidone (100 mg) twice daily for 7 and 10 d, respectively. The primary outcome measure was H. pylori eradication rate 4 wk after treatment by intention-to-treat and per protocol analysis, while the secondary outcome measures were symptom and sign changes at the end of treatment and 4 wk after the end of treatment, as well as the proportion of patients who developed adverse events.RESULTS: The demographic data of the four groups were not significantly different. Overall, 666 patients completed the scheme and were re-assessed with the ¹³C-urea breath test. The intention-to-treat analysis of the H. pylori eradication rates in Groups 1, 2, 3 and 4 were 74.44%, 82.78%, 78.89% and 86.11%, respectively. The H. pylori eradication rate in Group 4 was significantly higher than that in Group 1. According to the per protocol analysis, the H. pylori eradication rates in Groups 1, 2, 3 and 4 were 81.21%, 89.22%, 85.54% and 92.26%, respectively. The H. pylori eradication rate in Group 4 was significantly higher than that in Group 1. The number of adverse events was 15 (8.3%), 16 (8.9%), 15 (8.3%) and 17 (9.4%) in Groups 1, 2, 3 and 4, respectively, including dizziness, vomiting, diarrhea, nausea, skin rash, itchy skin, and malaise. The symptoms were relieved without special treatment in all of the patients.CONCLUSION: Both 7- and 10-d quadruple furazolidone-based therapies achieve satisfactory H. pylori eradication rates.     

Levofloxacin-based triple therapy in first-line treatment for Helicobacter pylori eradication

BACKGROUND:  The standard first-line therapies for Helicobacter pylori eradication are based on clarithromycin and amoxicillin or metronidazole. Recent studies suggested levofloxacin as an alternative option for both first-and second-line H. pylori eradication treatment.
AIMS:  To compare efficacy and tolerability of two different 7-day standard triple therapies versus 7-day levofloxacin-based triple therapy in first-line treatment for H. pylori infection.
METHODS:  Three hundred consecutive H. pylori positive patients were randomized to receive: clarithromycin, amoxicillin, esomeprazole (Group A: N = 100); clarithromycin, metronidazole, esomeprazole (Group B: N = 100); or clarithromycin, levofloxacin, esomeprazole (Group C: N = 100). H. pylori status was rechecked by ¹³C urea breath test 6 wk after the end of therapy.
RESULTS:  Sixteen out of 300 patients discontinued treatment because of the occurrence of side effects (Group A, 5; Group B, 7; Group C, 4). The eradication rates in intention to treat (ITT) and per protocol (PP) analyses were: Group A, 75% and 79%; Group B, 72% and 77.4%; and Group C, 87% and 90.6%. The eradication rate achieved with levofloxacin-based triple therapy was significantly higher than that with standard therapies in either ITT (87% vs 75%, p <0.05; 87% vs 72%, p <0.01;) or PP analysis (90.6% vs 79%, p <0.05; 90.6 vs 77.4, p <0.05). No difference was found between standard triple therapies. The incidence of side effects was similar among groups.
CONCLUSIONS:  A 7-day levofloxacin-based triple therapy can achieve higher H. pylori eradication rates than standard regimens. These data suggest levofloxacin-based regimens can be the most effective in first-line anti- H. pylori therapy, at least in the Italian population.     

Dual versus triple therapy in eradication of Helicobacter pylori

BACKGROUND/AIMS: Duodenal ulcers should be treated by eradication of Helicobacter pylori. This study compared the efficacy of a proton pump inhibitor together with one or two antibiotics in eradication therapy. METHODOLOGY: 177 patients who were H. pylori positive were randomized to receive 14 days of either: lansoprazole 30 mg bd and amoxicillin 1 g bd (LA), omeprazole 20 mg bd and amoxicillin 1 g bd (OA) or lansoprazole 30 mg bd, amoxicillin 1 g bd and clarithromycin 500 mg bd (LAC). The efficacy was assessed at four weeks and at six months after the end of treatment. Biopsies were taken for culture and bacterial sensitivity testing at inclusion and at four weeks after the end of treatment. RESULTS: 149 patients were evaluated for efficacy. The eradication rate was significantly higher in LAC (96%) compared to LA (51%) and OA (64%) treatments (P < 0.001). At baseline 17%, 21% and 19% of the patients in the LA, OA and LAC groups, respectively, were resistant to metronidazole and only one patient was resistant to clarithromycin. Post-treatment, four patients had acquired metronidazole resistance. CONCLUSIONS: LAC is more effective than LA and OA for eradication of H. pylori in duodenal ulcer disease.     

Helicobacter pylori eradication with doxycycline-metronidazole-bismuth subcitrate triple therapy.

Triple therapy containing tetracycline HCl is currently among the most efficient combination therapies for eradication of Helicobacter pylori. Substitution of doxycycline for tetracycline HCl offers advantages of less frequent dosing and extrarenal excretion. In this study patients with duodenal ulcer or non-ulcer dyspepsia positive for H. pylori were randomized to either doxycycline or tetracycline HCl triple therapy in conjunction with bismuth subcitrate and metronidazole. Of the 34 patients taking doxycycline, only 22 (65%) achieved H. pylori eradication at the 4-week rebiopsy, compared with 36 of 39 (92%) taking tetracycline HCl (p = 0.004). We conclude that doxycycline-containing triple therapy is less effective for H. pylori eradication and offers no clinical advantage over tetracycline HCl-containing triple therapy.     

Influence of Helicobacter pylori genotype on triple eradication therapy

BACKGROUND: The efficiency of Helicobacter pylori eradication varies geographically, as do many parameters that might affect therapeutic efficiency. The aims of this study were to investigate the relationship between different genotypes of H. pylori and bacterium-related histopathological lesions in patients with duodenal ulcer and to determine the effect of genotype on triple eradication therapy. METHODS: Helicobacter pylori infections were analyzed in 78 duodenal ulcer patients. The cytotoxin-associated gene (cagA) and vacuolating cytotoxin gene (vacA) subtype status of cultured strains were studied by PCR. Histopathological findings were graded using a described grading system. The patients were treated with triple-therapy regimens consisting of a proton pump inhibitor and two antibiotics twice daily for 7 days. Endoscopy was repeated at 4 weeks post-therapy to monitor ulcer healing and H. pylori eradication. RESULTS: The bacteria were genotyped from 66 patients, 57 of whom had H. pylori eradicated. The absence of cagA was associated with unsuccessful treatment. No difference was found with regard to vacA subtype between the successful and unsuccessful eradication groups. On histopathological examination, high H. pylori colonization density and intestinal metaplasia were associated with low eradication rate, while a high grade of neutrophil infiltration was associated with a significantly higher eradication rate. CONCLUSIONS: The data confirm the importance of cagA positivity as a predictor of successful eradication. When high H. pylori colonization density and intestinal metaplasia are present, therapy appears to be less effective. Therefore, these histopathological features may be involved in an unsuccessful therapeutic outcome.     

10天序贯和标准三联疗法根除幽门螺杆菌的疗效比较

目的评估新的序贯疗法对幽门螺杆菌的根除率。方法我院91例慢性胃炎患者纳入研究。幽门螺杆菌感染由组织学、尿素酶和尿素酶呼气试验评估。序贯疗法包括埃索美拉唑、阿莫西林治疗5天,随后以埃索美拉唑、克拉霉素和替硝唑治疗另外的5天。对照组标准三联疗法包括埃索美拉唑、阿莫西林和克拉霉素治疗10天。幽门螺杆菌的根除率以意向性分析(ITT)和完成治疗分析(PP)表示。根除疗效的判断根据治疗后6周的尿素酶呼气试验结果。结果序贯治疗对慢性胃炎患者的幽门螺杆菌感染获得86.36%(95%CI=81.19%-91.53%)和92.68%(95%CI=88.62%-96.74%)的根除率,但是和10天标准三联治疗相比较差异没有统计学意义。结论序贯治疗能获得较高的幽门螺杆菌根除率,但和10天标准三联治疗比较未获得显著的统计学差异。     

Pseudomembranous colitis associated with a triple therapy for Helicobacter pylori eradication

Helicobacter pylori(H.pylori)is one of the most common chronic bacterial infections in humans,affecting half of world’s population.Therapy for H.pylori infection has proven to be both effective and safe.The oneweek triple therapy including proton pump inhibitor,clarithromycin,and amoxicillin or metronidazole is still recommended as a first-line treatment to eradicate H.pylori infection in countries with low clarithromycin resistance.Generally,this therapy is well-tolerated,with only a few and usually minor side effects.However,rare but severe adverse effects such as pseudomembranous colitis have been reported,Clostridium difficile(C.difficile)infection being the main causative factor in all cases.We report the cases of two women who developed pseudomembranous colitis after a 1-wk triple therapy consisting of pantoprazole 20 mg bid,clarithromycin 500 mg bid,and amoxicillin 1 g bid to eradicate H.pylori infection.A limited colonoscopy showed typical appearance of pseudomembranous colitis,and the stool test for C.difficile toxins was positive.Rapid resolution of symptoms and negative C.difficile toxins were obtained in both patients with oral vancomycin.No relapse occurred during a four and eleven-month,respectively,follow up.These cases suggest that physicians should have a high index of suspicion for pseudomembranous colitis when evaluate patients with diarrhea following H.pylori eradication therapy.     

Effectiveness of minocycline-based triple therapy for eradication of Helicobacter pylori infection

Background: Widespread use of eradication therapy for Helicobacter pylori has increased the prevalence of clarithromycin‐resistant strains. The purpose of the present paper was to measure the in vitro antibacterial activity of minocycline against H. pylori, and study the effectiveness of minocycline‐based first‐ and second‐line eradication therapies. Methods: For first‐line therapy, 79 patients were randomly assigned to the treatment with rabeprazole, amoxicillin, and clarithromycin or with rabeprazole, amoxicillin, and minocycline. For second‐line therapy, 88 patients were tested for sensitivity to metronidazole: 67 patients with metronidazole‐sensitive strains received a 7‐day course of rabeprazole, minocycline, and metronidazole; the remaining 21 patients were given a 7‐day course of rabeprazole, minocycline, and faropenem. Results: There was virtually no resistance to minocycline among the strains tested. The eradication rate of H. pylori infection in first‐line therapy was significantly lower for minocycline‐containing regimen (38.5%, 15/39) than for clarithromycin‐containing regimen (82.5%, 33/40; P < 0.01). For second‐line therapy, a high eradication rate against metronidazole‐sensitive strains was obtained with rabeprazole, minocycline and metronidazole (85%, 57/67). Conclusions: A combination of rabeprazole, minocycline, and metronidazole is safe and effective for second‐line therapy of H. pylori infection. Because this regimen can be administered to patients with penicillin allergy and patients who suffer adverse reactions to amoxicillin, such as diarrhea and other digestive symptoms, it should be considered useful for second‐ and third‐line eradication therapy.     

Erosive duodenitis after eradication therapy for Helicobacter pylori]

We studied the characteristics of erosive duodenitis after eradication therapy for Helicobacter pylori (Hp). Fifty-nine patients with Hp-positive peptic ulcer disease were treated with a combination of amoxicillin, clarithromycin, lansoprazol, and polaprezinc Subsequently, erosive duodenitis developed in 18 (43.2%) of 44 patients in whom Hp was eradicated successfully. There were no significant differences in demographic characteristics between the patients in whom duodenitis developed and those whom it did not, except that the incidence of duodenal ulcer before treatment was highte in the former group than in the latter. Erosions were located not only in the anterior wall of the first portion of the duodenum but also in the posterior wall or the second portion. Our results suggest that the development erosive duodenitis after Hp eradication therapy is a favorable, rather than an unfavorable, event, because erosive duodenitis appeared only in the patients with in whom Hp was successfully eradicated, moreover, the patients with duodenitis had no complaints and had a good prognosis without follow-up treatment.     

Second-line levofloxacin-based triple schemes for Helicobacter pylori eradication

BackgroundThe recommended second-line therapy for Helicobacter pylori (H. pylori) eradication is a quadruple regimen that fails in up to 30% of patients. Several recent studies suggest levofloxacin-based triple therapies as an alternative rescue treatment. However, dosage and length of levofloxacin-based regimens have not been established.AimTo compare the efficacy and tolerability of four second-line levofloxacin-based schemes for H. pylori eradication.MethodsOne hundred and sixty patients (aged 18–70 years, 72 male patients) who were H. pylori positive after standard triple therapies were randomised to receive esomeprazole 20 mg b.d. and amoxicillin 1 g b.d. plus levofloxacin 500 mg o.d., for 7 or 10 days (Groups A and B) or levofloxacin 500 mg b.d. for 7 days or 10 days (Groups C and D). H. pylori status was assessed by 13-C Urea Breath Test or rapid urease test, before and 6 weeks after therapy. Incidence of side effects was evaluated by a questionnaire.ResultsNo dropouts were observed. Eradication of H. pylori infection was successful in: 65% of patients in Group A; 90% in Group B; 70% in Group C; 85% in Group D. Based upon duration of treatment, eradication rates were: 67.5% in 7 days groups and 87.5% in 10 days groups (p = 0.004). Dosage of levofloxacin did not affect the eradication rates (77.5% both in the once daily and twice daily groups).Mild adverse events were reported overall in 16% of patients (22.5% in 7 days groups; 27.5% in 10 days groups; p = 0.58; 12% in the once daily group; 32.5% in the twice daily group; p = 0.04).Conclusions10 days levofloxacin-based second-line regimens were effective in curing H. pylori infection in more than 85% of patients with a lower incidence of adverse effects in levofloxacin single-dosage scheme. The 10 days levofloxacin-based regimens were more effective than 7 days course of treatment showing that duration of therapy is the crucial factor affecting eradication rate.     

含莫西沙星的三联疗法作为根除幽门螺杆菌一线方案的Meta分析

目的 综合分析含莫西沙星的三联方案作为根除幽门螺杆菌（Hp）一线方案的疗效.方法 检索比较含莫西沙星的三联方案和标准三联方案根除幽门螺杆菌治疗的随机对照临床试验,进行荟萃分析.结果 共有7项随机对照试验符合人选标准,共纳入899例患者.基于意向治疗分析的结果显示含莫西沙星组Hp根除率为85.7%,标准治疗组为74.7%,差异有显著性（P〈0.0001）.基于按符合方案集分析的结果显示含莫西沙星组Hp根除率为86.5%,标准治疗组为76.1%,差异有显著性（P〈0.0001）.进一步行敏感性分析显示,纳入高质量研究、中文研究、疗程7天的研究和不同疾病谱的研究时结果均未出现变化.结论 含莫西沙星的三联治疗方案有较高的Hp根除率,且优于目前的标准治疗方案,可以作为根除Hp的一线治疗方案.     

Azithromycin-containing versus standard triple therapy for Helicobacterpylori eradication： A meta-analysis

AIM: To evaluate whether adding azithromycin to firstline Helicobacter pylori (H pylori ) eradication improved eradication and reduced side effects. METHODS: Eligible articles were identified by searches of electronic databases. We included all randomized trials that compared azithromycin-containing with standard triple-therapy regimens for first-line treatment of H pylori infection. Statistical analysis was performed with Review Manager 5.0.10. Sub-analyses were also performed.RESULTS: We identified 14 randomized trials (1431 patients). Pooled H pylori eradication rates were 72.01% (95% CI: 58.09%-85.93%) and 69.78% (95% CI: 66.47%-73.09%) for patients with or without azithromycin by intention-to-treat analysis, and the odds ratio (OR) was 1.17 (95% CI: 0.64-2.14). The occurrence of side effects differed significantly and was 15.81% (95% CI: 12.50%-19.12%) and 25.20% (95% CI: 21.44%-28.96%) for treatment with or without azithromycin, respectively, and the summary OR was 0.58 (95% CI: 0.41-0.82). Furthermore, the azithromycin-containing group had a lower occurrence of diarrhea, nausea and taste disturbance. CONCLUSION: Our review suggests that azithromycincontaining triple-therapy regimens could be equally effective in eradication of H pylori compared with standard first-line triple-therapy regimens.