Third-line and rescue therapy for refractory Helicobacter pylori infection: A systematic review

• Published in: World journal of gastroenterology : WJG Vol. 29; no. 2; pp. 390 - 409
• Main Authors: de Moraes Andrade, Pedro Vieira, Monteiro, Yan Mosca, Chehter, Ethel Zimberg
• Format: Journal Article
• Language: English
• Published: United States Baishideng Publishing Group Inc 14.01.2023
• Subjects: Anti-Bacterial Agents - adverse effects; Bismuth - therapeutic use; Drug Resistance, Bacterial; Drug Therapy, Combination; Helicobacter Infections - diagnosis; Helicobacter Infections - drug therapy; Helicobacter pylori; Humans; Levofloxacin - therapeutic use; Macrolides - therapeutic use; Metronidazole - therapeutic use; Proton Pump Inhibitors - adverse effects; Rifabutin - adverse effects; Systematic Reviews; Tetracycline - therapeutic use; Refractory infection; Treatment; Helicobacter pylori; Third-line therapy; Eradication; Rescue therapy
• ISSN: 1007-9327; 2219-2840
• DOI: 10.3748/wjg.v29.i2.390

Due to increasing resistance rates of ( ) to different antibiotics, failures in eradication therapies are becoming more frequent. Even though eradication criteria and treatment algorithms for first-line and second-line therapy against infection are well-established, there is no clear recommendation for third-line and rescue therapy in refractory infection. To perform a systematic review evaluating the efficacy and safety of rescue therapies against refractory infection. A systematic search of available rescue treatments for refractory infection was conducted on the National Library of Medicine's PubMed search platform based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized or non-randomized clinical trials and observational studies evaluating the effectiveness of infection rescue therapies were included. Twenty-eight studies were included in the analysis of mean eradication rates as rescue therapy, and 21 of these were selected for analysis of mean eradication rate as third-line treatment. For rifabutin-, sitafloxacin-, levofloxacin-, or metronidazole-based triple-therapy as third-line treatment, mean eradication rates of 81.6% and 84.4%, 79.4% and 81.5%, 55.7% and 60.6%, and 62.0% and 63.0% were found in intention-to-treat (ITT) and per-protocol (PP) analysis, respectively. For third-line quadruple therapy, mean eradication rates of 69.2% and 72.1% were found for bismuth quadruple therapy (BQT), 88.9% and 90.9% for bismuth quadruple therapy, three-in-one, Pylera (BQT-Pylera), and 61.3% and 64.2% for non-BQT) in ITT and PP analysis, respectively. For rifabutin-, sitafloxacin-, levofloxacin-, or metronidazole-based triple therapy as rescue therapy, mean eradication rates of 75.4% and 78.8%, 79.4 and 81.5%, 55.7% and 60.6%, and 62.0% and 63.0% were found in ITT and PP analysis, respectively. For quadruple therapy as rescue treatment, mean eradication rates of 76.7% and 79.2% for BQT, 84.9% and 87.8% for BQT-Pylera, and 61.3% and 64.2% for non-BQT were found in ITT and PP analysis, respectively. For susceptibility-guided therapy, mean eradication rates as third-line and rescue treatment were 75.0% in ITT and 79.2% in PP analysis. We recommend sitafloxacin-based triple therapy containing vonoprazan in regions with low macrolide resistance profile. In regions with known resistance to macrolides or unavailability of bismuth, rifabutin-based triple therapy is recommended.