Update on the second-line treatment of Helicobacter pylori infection: a narrative review

Chih-An Shih; Chang-Bih Shie; Wei-Chen Tai; Seng-Kee Chuah; Hsi-Chang Lee; Ping-I Hsu

doi:10.1177/17562848231192750

Update on the second-line treatment of Helicobacter pylori infection: a narrative review

Therap Adv Gastroenterol. 2023 Sep 4:16:17562848231192750. doi: 10.1177/17562848231192750. eCollection 2023.

Authors

Chih-An Shih^{1

2}, Chang-Bih Shie³, Wei-Chen Tai⁴, Seng-Kee Chuah⁴, Hsi-Chang Lee⁵, Ping-I Hsu⁶

Affiliations

¹ Division of Gastroenterology and Hepatology, Department of Internal Medicine, Antai Medical Care Corporation, Antai Tian-Sheng Memorial Hospital, Pingtung County.
² Department of Nursing, Meiho University, Pingtung County.
³ Division of Gastroenterology, Department of Internal Medicine, An Nan Hospital, China Medical University, Tainan.
⁴ Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, and Chang Gung University College of Medicine, Taoyuan.
⁵ Division of Gastroenterology and Hepatology, Department of Internal Medicine, Renai Branch, Taipei City Hospital, 10, Section 4, Ren'ai Road, Da'an District 106, Taipei.
⁶ Division of Gastroenterology and Hepatology, Department of Internal Medicine, An Nan Hospital, China Medical University, No. 66, Sec. 2, Changhe Road., Annan Dist., Tainan City 70965.

Abstract

A standard bismuth quadruple therapy, a fluoroquinolone-containing triple (or quadruple) therapy or a proton pump inhibitor (PPI)-amoxicillin high-dose dual therapy has been recommended as a second-line treatment for Helicobacter pylori infection by the Maastricht VI/Florence Consensus Report. The major shortcoming of levofloxacin-amoxicillin triple therapy is low cure rate for eradicating levofloxacin-resistant strains. With the rising prevalence of levofloxacin-resistant strains, levofloxacin-amoxicillin triple therapy cannot reliably achieve a high eradication rate for second-line treatment of H. pylori infection in most countries now. The present article aims to review current second-line eradication regimens with a per-protocol eradication rate exceeding 85% in most geographic areas. Recently, a novel tetracycline-levofloxacin quadruple therapy consisting of a PPI, bismuth, tetracycline, and levofloxacin for rescue treatment of H. pylori infection has been developed. The new therapy achieved a higher per-protocol eradication rate than levofloxacin-amoxicillin triple treatment in a randomized controlled trial (98% versus 69%). Additionally, the tetracycline-levofloxacin quadruple therapy also exhibits a higher eradication rate than amoxicillin-levofloxacin quadruple therapy. High-dose dual PPI-amoxicillin therapy is another novel second-line treatment for H. pylori infection. The new therapy can achieve an eradication rate of 89% by per-protocol analysis for the second-line treatment in Taiwan. Recently, levofloxacin-based sequential quadruple therapy and potassium-competitive acid blocker have also been applied in the second-line treatment of H. pylori infection. A meta-analysis revealed that a vonoprazan-based regimen has significant superiority over a PPI-based regimen for second-line H. pylori eradication therapy. In conclusion, the eradication rate of levofloxacin-amoxicillin triple therapy is suboptimal in the second-line treatment of H. pylori infection now. Currently, a standard bismuth quadruple therapy (tetracycline-metronidazole quadruple therapy), a tetracycline-levofloxacin quadruple therapy, an amoxicillin-levofloxacin quadruple therapy, a levofloxacin-based sequential quadruple therapy or a high-dose PPI-amoxicillin dual therapy is recommended for the second-line treatment of H. pylori infection.

Keywords: Helicobacter pylori; amoxicillin-levofloxacin quadruple therapy; bismuth quadruple therapy; high-dose dual therapy; second-line treatment; tetracycline-levofloxacin quadruple therapy.

Publication types

Review