What’s the best secondary treatment for patients who fail initial triple therapy for H pylori?
EVIDENCE-BASED ANSWER:
Treating patients with Helicobacter pylori infection who have failed clarithromycin-based triple therapy with either levofloxacin-based triple therapy (with amoxicillin and a proton pump inhibitor [PPI]) or a bismuth-based quadruple therapy produces cure rates of 75% to 81%. Ten-day regimens produce higher cure rates than 7-day regimens. Repeating the initial clarithromycin-based triple therapy cures fewer than half of patients (strength of recommendation [SOR]: A, meta-analyses of randomized controlled trials [RCTs]).
Treating with a metronidazole-based triple therapy (with amoxicillin and a PPI) also produces high (87%) cure rates (SOR: A, meta-analyses of RCTs in exclusively Japanese populations).
Selecting a secondary treatment regimen based on H pylori antibiotic susceptibility testing probably doesn’t improve cure rates over empiric antibiotic treatment (SOR: B, meta-analyses of RCTs with conflicting results). However, after 2 treatment failures it may be necessary (SOR: C, expert opinion-based guidelines).
Bismuth-based quadruple therapy has a more complex dosing regimen, and bismuth isn’t available in some countries. Rising rates of H pylori resistance to levofloxacin in certain areas could make levofloxacin-based triple therapy less effective in the future (SOR: C, expert opinion-based guidelines).
Two secondary antibiotic regimens show similar cure rates
A meta-analysis of 4 RCTs (total 460 patients) that compared susceptibility-guided antibiotic secondary treatment (SGT) with empiric antibiotic secondary treatment found no difference in cure rates, although the largest single RCT (172 patients) favored SGT.4
RECOMMENDATIONS
The Maastricht IV/Florence Consensus Report (a periodically updated European study group evaluating Helicobacter management) includes expert opinion-based guidelines for H pylori treatment that recommend using antibiotic susceptibility to select treatment regimens in the event of 2 treatment failures.5 The report also notes that bismuth-based quadruple therapy may not be available in all countries and has a more complex dosing regimen, and that local resistance to levofloxacin must be taken into account when prescribing levofloxacin-based triple therapy.
