“Rescue” regimens after Helicobacter pylori treatment failure

Abstract

Helicobacter pylori (H pylori ) infection is the main cause of gastritis, gastroduodenal ulcer disease, and gastric cancer. After more than 20 years of experience in H pylori treatment, in my opinion, the ideal regimen to treat this infection is still to be found. Currently, apart from having to know first-line eradication regimens well, we must also be prepared to face treatment failures. Therefore, in designing a treatment strategy we should not focus on the results of primary therapy alone, but also on the final (overall) eradication rate. The choice of a "rescue" treatment depends on which treatment is used initially. If a clarithromycinbased regimen was used initially, a subsequent metronidazole-based treatment (quadruple therapy) may be used afterwards, and then a levofloxacinbased combination would be a third "rescue" option. Alternatively, it has recently been suggested that levofloxacin-based rescue therapy constitutes an encouraging second-line strategy, representing an alternative to quadruple therapy in patients with previous PPI-clarithromycin-amoxicillin failure, with the advantage of efficacy, simplicity and safety. In this case, a quadruple regimen may be reserved as a third-line rescue option. Finally, rifabutin-based rescue therapy constitutes an encouraging empirical fourthline strategy after multiple previous eradication failures with key antibiotics such as amoxicillin, clarithromycin, metronidazole, tetracycline, and levofloxacin. Even after two consecutive failures, several studies have demonstrated that H pylori eradication can finally be achieved in almost all patients if several rescue therapies are consecutively given. Therefore, the attitude in H pylori eradication therapy failure, even after two or more unsuccessful attempts, should be to fight and not to surrender.

Review: Second-line rescue therapy of Helicobacter pylori infection

“…Furthermore, these encouraging (cumulative) results have been obtained when more than three consecutive treatments have been prescribed [Gisbert et al 2008a[Gisbert et al , 2005b. As an example, Seppala et al [2000] reported a cumulative eradication rate of 93% (intention-to-treat analysis) and even 100% (per-protocol analysis) after four empirical retreatments.…”

“…As previously mentioned, it has been generally recommended that performing culture after a first eradication failure is not necessary and therefore assessing H. pylori sensitivity to antibiotics only after failure of the second treatment may be suggested in clinical practice [Malfertheiner et al 2007;De Boer et al 2000b; European Helicobacter pylori Study Group 1997]. However, the utility of the culture (with consequent antibiotic susceptibility testing) and the moment when it must be performed after eradication failure are both controversial [Gisbert, 2008a[Gisbert, , 2005b. It is evident that, as pretreatment antibiotic resistance is the most important factor in nonresponse to initial treatment [Dore et al 2000;Houben et al 1999;Peitz et al 1999;Van Der Wouden et al 1999;Tompkins et al 1997], knowledge of the organism's antibiotic susceptibility may represents an aid in selecting the therapy regimen.…”

“…Some authors have evaluated, in the same study, different regimens after failure of two eradication treatments, which provide interesting information about cumulative, and not only absolute, eradication rates [Gisbert et al 2008a[Gisbert et al , 2005b. For example, in the study by Gasbarrini et al [2000a], a total of 2606 patients were administered a PPI, tinidazole and clarithromycin for 1 week.…”

Helicobacter pylori antibiotic resistance in Brazil: clarithromycin is still a good option

“…However, in recent times, eradication rates in practice for many of the first-line treatment regimens has fallen well below these levels, generally due to the connected factors of poor compliance with medication (11,22) . With failure of first-line therapy, the need for effective second-line therapy is clear (13) . The most common used second-line therapies are bismuth-based and levofloxacin-based ones.…”

Up-to-date standarts of eradication therapy. аre all the qUestions answered? R.A. AbdoulkhAkov, S.R. AbdoulkhAkov

“…Необходимость в проведе-нии терапии второй линии очевидна хотя бы потому, что терапия первой линии оказывается неудачной примерно в 20% случаев [17]. Еще в 2001 г. было показано, что схе-ма, содержащая ИПП, препарат висмута, метронидазол и тетрациклин, приводит к уничтожению H.pylori у 76% пациентов с предшествующей неэффективной терапией первой линии.…”