Quadruple regimens for helicobacter pylori infection

Abstract

An effective therapy against Helicobacter pylori (H. pylori) is defined as one achieving at least a 90 % eradication rate. Treatment results are best when reliable schemes are based on susceptibility testing; however, empiric eradication therapies are generally prescribed. Standard triple therapy has been the most recommended regimen, but its efficacy is currently suboptimal worldwide due to rising clarithromycin resistance. Consequently, the scientific community has recently taken on the task of rescuing old empiric quadruple regimens to overcome antibiotic resistance. The choice of empiric therapy may depend on patient previous antibiotic treatment, local patterns of antibiotic resistance, and drug availability. Currently, the preferred first-line choices are bismuth quadruple therapy and non-bismuth quadruple concomitant therapy. A 14-day bismuth quadruple therapy is expected to have a 95 % efficacy regardless of metronidazole resistance, but its Achilles heel is compliance, besides drug availability. On the contrary, the efficacy of concomitant therapy is challenged by dual clarithromycin and metronidazole resistance. Optimization of all regimens (increased duration, adequate proton pump inhibitor and antibiotic doses, and dosing intervals) is indispensable to maximize their efficacy. Treatment failures should be managed with an alternate regimen using an optimized combination of different antibiotics. Bismuth-containing fluoroquinolone quadruple therapy and bismuth quadruple therapy (if not used previously) have recently shown the best results. Due to regional variation in H. pylori resistance patterns, the golden rule for choice of treatment is only to use therapies that work locally (>90–95 % success) and to monitor their effectiveness over time.