Treatment of Helicobacter Pylori infection: optimization strategies in a high resistance era.
BACKGROUND
Treatment of Helicobacter pylori (H. pylori) infection is paramount for the management of prevalent gastrointestinal disorders and in the prevention of gastric cancer. Due to increasing antimicrobial resistance, performance of standard triple therapies has now declined to unacceptably low levels.


METHODS
In this article: i) we critically revise optimization tools aiming to improve the outcome of standard treatments; ii) we provide updated evidence on the efficacy and rationale for the use of several non-bismuth quadruple regimens in clinical practice, recommended as preferred empirical therapies in areas of high clarithromycin resistance.


CONCLUSIONS
Prolonged (14-day) treatment duration may boost the efficacy of standard triple therapy by approximately 5%. Use of a high-dose PPI and/or new-generation PPIs, rabeprazole and esomeprazole, might improve eradication rates, particularly in regions where the CYP2C19 rapid metabolizer phenotype is prevalent. Adjunctive probiotics may be considered to improve treatment tolerability, though more data are required to better define their role in H. pylori eradication. Among non-bismuth quadruple regimens, both concomitant and sequential therapies are appropriate options for high-resistance settings; however, concomitant therapy appears to be less impaired by dual clarithromycin/metronidazole resistance. Hybrid therapy is a promising new alternative which seems not to be inferior to concomitant therapy.
a 1 Athens Medical P. Faliron General Hospital, Department of Gastroenterology , 17562 Athens, Greece +306 9 32 35 62 78 ; +302 1 04 11 53 75 ; georgpap@ath.forthnet.gr.
Sotirios D
SD
Georgopoulos
b 2 General Hospital of Rhodes, First Department of Internal Medicine , 85100 Rhodes, Greece.
Vasilios
V
Papastergiou
b 2 General Hospital of Rhodes, First Department of Internal Medicine , 85100 Rhodes, Greece.
Stylianos
S
Karatapanis
D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D017291:Clarithromycin / Q000627:therapeutic use; D065731:Cytochrome P-450 CYP2C19 / Q000378:metabolism; D024881:Drug Resistance, Bacterial; D004359:Drug Therapy, Combination; D064098:Esomeprazole / Q000627:therapeutic use; D016481:Helicobacter Infections / Q000188:drug therapy*; D016480:Helicobacter pylori / Q000187:drug effects*; D006801:Humans; D008795:Metronidazole / Q000627:therapeutic use; D019936:Probiotics / Q000627:therapeutic use; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D013274:Stomach Neoplasms / Q000517:prevention & control
D000900:Anti-Bacterial Agents; D054328:Proton Pump Inhibitors; D008795:Metronidazole; D065731:Cytochrome P-450 CYP2C19; D017291:Clarithromycin; D064098:Esomeprazole
concomitant; hybrid; optimization; probiotics; sequential; standard triple therapy