"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 clarithromycin-based regimen was used initially, a subsequent metronidazole-based treatment (quadruple therapy) may be used afterwards, and then a levofloxacin-based 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 fourth-line 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.

Figure 1

Meta-analysis comparing H pylori eradication efficacy with levofloxacin-based triple regimens versus quadruple therapy, as second-line “rescue” regimen after failure of a proton pump inhibitor-amoxicillin-clarithromycin.

Figure 2

Cumulative H pylori eradication rates with three consecutive eradication treatments.

Figure 3

Choice of a empirical retreatment regimen, without culture and antimicrobial sensitivity testing, after failure of proton pump inhibitor (PPI), amoxicillin and clarithromycin combination. Quadruple therapy: Combination of PPI, bismuth, tetracycline and nitroimidazole (metronidazole or tinidazole).