Levofloxacin or Clarithromycin-based quadruple regimens: what is the best alternative as first-line treatment for Helicobacter pylori eradication in a country with high resistance rates for both antibiotics?

Abstract

Background Helicobacter pylori eradication rates in Portugal are declining, due to increased resistance of this bacterium to antimicrobial agents, especially Clarithromycin. Quadruple Levofloxacin-containing regimens could be an option for first-line treatment, but its efficacy should be evaluated as fluoroquinolone resistance is rapidly increasing.Our aim was to compare the efficacy of Clarithromycin and Levofloxacin-based sequential quadruple therapies as first-line treatment options and determine factors associated with treatment failure.MethodsA total of 200 Helicobacter pylori infected patients were retrospectively included (female 57.5%; average age: 53.2 ± 15.7) and received either 10-day sequential therapy (Proton-Pump Inhibitor + Amoxicillin 1 g bid for 5 days and Proton-Pump Inhibitor + Clarithromycin 500 mg + Metronidazole/Tinidazole 500 mg bid/tid in the following 5 days; group A) or a 10-day modified sequential therapy with Levofloxacin 500 mg id instead of Clarithromycin (group B). Eradication was confirmed with urea breath test. Variables that could influence success rate were analyzed.ResultsThere were no differences between groups in terms of gender, age, smoking habits and indications for treatment. The eradication rate obtained with Clarithromycin-based sequential treatment was significantly higher than with Levofloxacin-based therapy (90%, CI95%: 84–96% vs. 79%, CI95%: 71–87%, p = 0.001). Using full-dose proton-pump inhibitor and high-dose Metronidazole in group A, and full-dose proton-pump inhibitor and prescription from a Gastroenterologist in group B were associated with eradication success.ConclusionsTen-day Levofloxacin-based sequential treatment achieved inadequate efficacy rate (<80%) and should not be adopted as first-line therapy. Standard sequential therapy showed significantly better results in this naïve population. Using full-dose proton-pump inhibitor and higher doses of Metronidazole is essential to achieve such results.Electronic supplementary materialThe online version of this article (doi:10.1186/s12876-017-0589-6) contains supplementary material, which is available to authorized users.

Sequential Therapy for First-Line Helicobacter pylori Eradication: 10- or 14-Day Regimen?

“…Curing H. pylori infection still remains a challenge in clinical practice. The 10-day sequential therapy, suggested as first-line therapy in the current Italian guidelines [3], has been proven to be effective in several countries, achieving eradication rates as high as 91.1%-93.7% in Italy [7,11], 92.5-95% in Turkey [12,13], 94.2% in Slovenia [14], 90% in Portugal [15], 90% in Belgium [16], 95.9% in Israel [17], 94% in Thailand [18], 91.9% in Taiwan [19], 90.3% in Singapore [20], and 88.6% in the United Arab Emirates [21]. In detail, the 10-day sequential therapy was found to be equally effective -but cheaper -than J Gastrointestin Liver Dis, March 2019 Vol.…”

Efficacy of bismuth‐based quadruple therapy for eradication of Helicobacter pylori infection based on previous antibiotic exposure: A large‐scale prospective, single‐center clinical trial in China

“…Therefore, treatment‐naïve adults who never or rarely used antibiotics, including amoxicillin, clarithromycin, and metronidazole, were allocated to receive regimen A (nitroimidazole‐free). The combination of amoxicillin and clarithromycin is capable of increasing the concentrations of intracellular drugs, reducing the bacterial colonization, thereby playing a stronger antibacterial effect against H pylori strains, including those resistant to clarithromycin 38‐41 . Thus, an eradication rate of 94.6% was achieved by regimen A for treatment‐naïve adults.…”

First-line therapies for Helicobacter pylori eradication: a critical reappraisal of updated guidelines

“…When considering only data from studies published in the last 5 years, the cure rate following sequential therapy was still 90-92.6% in 5 Italian studies with more than 1000 patients [26,38-41], and 73% in another study with 100 cases [42]. A similarly high success rate of sequential therapy has been observed in studies recently performed in Slovenia (94.2%) [43], Portugal (90%) [44], Belgium (90%) [3], Israel (95.9%) [45], Thailand (94%) [46], Taiwan (91.9%) [47], Singapore (90.3%) [48], and the United Arab Emirates (88.6%) [49], suggesting that this therapy is still effective in several countries. Based on these findings, Italian, Slovenian, or Portuguese physicians could inopportunely deprive their patients a priori of a still effective therapy by following the European guidelines.…”