What's the best secondary treatment for patients who fail initial triple therapy for H pylori?
Q: What's the best secondary treatment for patients who fail initial triple therapy for H pylori? Evidence-based answer: treating patients with Helicobacter pylori infection who have failed clarithromycin-based triple therapy with either levofloxacin-based triple therapy (with amoxicillin and a proton pump inhibitor [PPI]) or a bismuth-based quadruple therapy produces cure rates of 75% to 81%. Ten-day regimens produce higher cure rates than 7-day regimens. Repeating the initial clarithromycin-based triple therapy cures fewer than half of patients (strength of recommendation [SOR]: A, meta-analyses of randomized controlled trials [RCTs]). Treating with a metronidazole-based triple therapy (with amoxicillin and a PPI) also produces high (87%) cure rates (SOR: A, meta-analyses of RCTs in exclusively Japanese populations). Selecting a secondary treatment regimen based on H pylori antibiotic susceptibility testing probably doesn't improve cure rates over empiric antibiotic treatment (SOR: B, meta-analyses of RCTs with conflicting results). However, after 2 treatment failures it may be necessary (SOR: C, expert opinion-based guidelines). Bismuth-based quadruple therapy has a more complex dosing regimen, and bismuth isn't available in some countries. Rising rates of H pylori resistance to levofloxacin in certain areas could make levofloxacin-based triple therapy less effective in the future (SOR: C, expert opinion-based guidelines).
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