title: Pharmacological regimens for eradication of Helicobacter pylori: an overview of systematic reviews and network meta-analysis.
abstract: BACKGROUND
  Approximately half of the world's population is infected with Helicobacter pylori (H.pylori), a bacterium shown to be linked with a series of gastrointestinal diseases. A growing number of systematic reviews (SRs) have been published comparing the effectiveness of different treatments for H.pylori infection but have not reached a consistent conclusion. The objective of this study is to provide an overview of SRs of pharmacological therapies for the eradication of H.pylori.
  
  
  METHODS
  Major electronic databases were searched to identify relevant SRs published between 2002 and February 2016. Studies were considered eligible if they included RCTs comparing different pharmacological regimens for treating patients diagnosed as H.pylori infected and pooled the eradication rates in a meta-analysis. A modified version of the 'A Measurement Tool to Assess Systematic Reviews' (AMSTAR) was used to assess the methodological quality. A Bayesian random effects network meta-analysis (NMA) was conducted to compare the different proton pump inhibitors (PPI) within triple therapy.
  
  
  RESULTS
  30 SRs with pairwise meta-analysis were included. In triple therapy, the NMA ranked the esomeprazole to be the most effective PPI, followed by rabeprazole, while no difference was observed among the three old generations of PPI for the eradication of H.pylori. When comparing triple and bismuth-based therapy, the relative effectiveness appeared to be dependent on the choice of antibiotics within the triple therapy; moxifloxacin or levofloxacin-based triple therapy were both associated with greater effectiveness than bismuth-based therapy as a second-line treatment, while bismuth-based therapy achieved similar or greater eradication rate compared to clarithromycin-based therapy. Inconsistent findings were reported regarding the use of levofloxacin/moxifloxacin in the first-line treatment; this could be due to the varied resistant rate to different antibiotics across regions and populations. Critical appraisal showed a low-moderate level of overall methodological quality of included studies.
  
  
  CONCLUSIONS
  Our analysis suggests that the new generation of PPIs and use of moxifloxacin or levofloxacin within triple therapy as second-line treatment were associated with greater effectiveness. Given the varied antibiotic resistant rate across regions, the appropriateness of pooling results together in meta-analysis should be carefully considered and the recommendation of the choice of antibiotics should be localized.
authors.affiliation: Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK. yiqiao.xin@glasgow.ac.uk.
authors.forename: Yiqiao
authors.identifier: http://orcid.org/0000-0001-5856-3103
authors.initials: Y
authors.lastname: Xin
authors.affiliation: Knowledge and Information, Healthcare Improvement Scotland, Glasgow, UK.
authors.forename: Jan
authors.initials: J
authors.lastname: Manson
authors.affiliation: Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
authors.forename: Lindsay
authors.initials: L
authors.lastname: Govan
authors.affiliation: Knowledge and Information, Healthcare Improvement Scotland, Glasgow, UK.
authors.forename: Robin
authors.initials: R
authors.lastname: Harbour
authors.affiliation: Scottish Intercollegiate Guideline Network (SIGN), NHS Education for Scotland, Royal College of General Practitioners (Scotland), Mill Lane Surgery, Edinburgh, UK.
authors.forename: Jenny
authors.initials: J
authors.lastname: Bennison
authors.affiliation: Department of gastroenterology, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK.
authors.forename: Eleanor
authors.initials: E
authors.lastname: Watson
authors.affiliation: Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
authors.forename: Olivia
authors.initials: O
authors.lastname: Wu
mesh_terms: D006801:Humans; D000863:Antacids / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001729:Bismuth / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D016481:Helicobacter Infections / Q000188:drug therapy; D016480:Helicobacter pylori; D006635:Histamine H2 Antagonists / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D000078202:Systematic Reviews as Topic; D015201:Meta-Analysis as Topic
chemical_list: D000863:Antacids; D000900:Anti-Bacterial Agents; D001729:Bismuth; D006635:Histamine H2 Antagonists; D054328:Proton Pump Inhibitors
keywords: Eradication; Helicobacter pylori; Network meta-analysis; Systematic review