Review article: non-bismuth quadruple (concomitant) therapy for eradication of Helicobater pylori

Abstract

Aliment Pharmacol Ther 2011; 34: 604–617 Summary Background Traditional standard triple therapy for Helicobacter pylori infection (PPI‐clarithromycin‐amoxicillin) can easily be converted to non‐bismuth quadruple (concomitant) therapy by the addition of a nitroimidazole twice daily. Aim To critically review evidence on the role of non‐bismuth quadruple therapy (PPI‐clarithromycin‐amoxicillin‐nitroimidazole) in the treatment of H. pylori infection. Methods Bibliographical searches were performed in MEDLINE and relevant congresses. Results The first randomised comparison of the non‐bismuth quadruple therapy and the sequential (PPI‐amoxicillin 5 days plus PPI‐clarithromycin‐nitroimidazole 5 days) regimens recently concluded that both were similar in terms of efficacy and safety and that the sequential administration protocol may be unnecessarily complex. Several randomised controlled trials (and one meta‐analysis) have demonstrated that non‐bismuth quadruple therapy is more effective than and is equally well tolerated as standard triple therapy. A meta‐analysis of 15 studies (1723 patients) revealed a mean H. pylori cure rate (intention‐to‐treat) of 90% for non‐bismuth quadruple therapy. A tendency towards better results with longer treatments (7–10 days vs. 3–5 days) has been observed, so it seems reasonable to recommend the length of treatment by achieving maximal cure rates (10 days). Clarithromycin resistance may reduce the efficacy of non‐bismuth quadruple therapy, although the decrease in eradication rates seems to be far lower than in standard triple therapy. Experience with the non‐bismuth quadruple therapy in patients with metronidazole‐resistant strains is still very limited. Conclusions Non‐bismuth quadruple (concomitant) therapy appears to be an effective, safe, and well‐tolerated alternative to triple therapy and is less complex than sequential therapy. Therefore, this regimen appears well suited for use in settings where the efficacy of triple therapy is unacceptably low.

Antibiotic treatment forHelicobacter pylori: Is the end coming?

“…Eradication rates for concomitant and sequential therapies were 100% vs 75% for clarithromycin-resistant strains and 75% vs 60% for clarithromycin-resistant/metronidazoleresistant strains [97] . A meta-analysis of 15 studies showed a mean H. pylori eradication rate of 90% by ITT analysis for concomitant therapy and reported that longer treatment improved the outcomes compared to STT [98] .…”

Ensuring the highest eradication rates in H. pylori: the case of non-bismuth quadruple concomitant therapy

“…Although three metaanalyses have concluded that quadruple therapy is equivalent to triple therapy, the basal studies pooled for these analyses used 7 day regimens and were conducted years ago when the rates of clarithromycin resistance were still low [10][11][12]. Unluckily, the difficulty to access some of the compounds used in this treatment (bismuth salts and tetracycline) in several countries, and until the new single capsule formulation is available worldwide [13], forces us to seek for non-bismuth-based alternatives [14,15].…”

In vitro synergistic effect of Hibiscus sabdariffa aqueous extract in combination with standard antibiotics against Helicobacter pylori clinical isolates

“…Numerous treatment strategies containing a proton pump inhibitor and combination of two or more antibiotics such as clarithromycin (CLA), amoxicillin (AMX) and metronidazole (MTZ) or tetracycline (TET) have been successfully used to eradicate HP infection (Nagahara et al 2000;Chaabane & Al-Adhba 2015). Although the efficacy of such strategies in the therapy, the increasing use of antibiotics has led to the problem of drug-resistant strains (Essa et al 2009;Gisbert & Calvet 2011). Resistance rates have been reported vary from 0 to 45% for CLA, from 0 to 33% for AMX, from 10% to 90% for MTZ, from 6% to 21% for levofloxacin and from 5% to 59% for TET (Karamanolis et al 2014;O'Connor et al 2014;Song et al 2014).…”