Non-Bismuth Quadruple (Concomitant) Therapy for Eradication of H-pylori: Standard vs. Optimized (14-Day, High-Dose PPI) Regimen

BACKGROUND:Helicobacter pylori infection is usually treated with a proton pump inhibitor (PPI), amoxicillin and clarithromycin, but it fails in ≥ 20% of patients. AIM: To estimate, by a systematic review and meta-analyses, the most effective rescue treatments after the failure of a first-line therapy with PPI, amoxicillin and clarithromycin in H. pylori eradication. METHODS: Selection of studies: Meta-analyses were performed with randomized clinical trials (RCT) that assessed the efficacy of second-line regimens; the generic inverse variance was applied on prospective and retrospective studies. Inclusion criteria: studies treating H. pylori-positive patients after clarithromycin-amoxicillin-PPI failure. Exclusion criteria: Secondline treatment based on the antibiotic sensitivity, or if the confirmation of eradication were made only by serology, PCR or polyclonal stool antigen test. Search strategy: Bibliographical searches were performed in PubMed, CINAHL, Cochrane Library, ClinicalTrials.gov, DDW y EHSG, up to April 2013. Data synthesis: Intention to treat eradication rate. RESULTS: The efficacies of the second-line treatments are shown on the table attached. A metaanalysis comparing the triple therapy with levofloxacin-amoxicillin-PPI against the quadruple bismuth-metronidazole-tetracycline-PPI regimen showed a non-statistically significant tendency towards better results levofloxacin (OR = 1.74; 95% C.I. = 0.83-3.67; p = 0.14; I2 = 79%; 6 studies; 1,057 patients). CONCLUSION: The most effective second-line treatments, after a clarithromycin-amoxicillin-PPI failure, are the metronidazole-amoxicillin-PPI or a 10 days levofloxacin-amoxicillin-PPI therapy. More high quality trials, performed outside Japan, are needed to verify the efficacy of the 14 days dual therapy with amoxicillin-PPI.