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World J Gastrointest Pathophysiol. Nov 15, 2014; 5(4): 392-399
Published online Nov 15, 2014. doi: 10.4291/wjgp.v5.i4.392
Treatment of Helicobacter pylori infection: Past, present and future
Vasilios Papastergiou, Sotirios D Georgopoulos, Stylianos Karatapanis
Vasilios Papastergiou, Stylianos Karatapanis, Department of Internal Medicine, General Hospital of Rhodes, 85100 Rhodes, Greece
Sotirios D Georgopoulos, Department of Gastroenterology, Athens Medical, P. Faliron Hospital, 17562 Athens, Greece
Author contributions: Papastergiou V contributed to conception and design, drafting the article; Georgopoulos SD contributed to drafting the article, revising the article critically for important intellectual content; Karatapanis S contributed to final approval of the version to be published.
Correspondence to: Stylianos Karatapanis, MD, PhD, Department of Internal Medicine, General Hospital of Rhodes, 10 Kalopetras Str, 85100 Rhodes, Greece. stylkar@otenet.gr
Telephone: +30-224-1080456 Fax: +30-224-1066410
Received: February 12, 2014
Revised: April 15, 2014
Accepted: July 17, 2014
Published online: November 15, 2014
Processing time: 280 Days and 3.9 Hours
Abstract

Helicobacter pylori (H. pylori) is a major human pathogen associated with significant morbidity and mortality. However, after decades of efforts, treatment of H. pylori remains a challenge for physicians, as there is no universally effective regimen. Due to the rising prevalence of antimicrobial resistance, mainly to clarithromycin, efficacy of standard triple therapies has declined to unacceptably low levels in most parts of the world. Novel regimens, specifically experimented to improve the therapeutic outcome against antibiotic-resistant H. pylori strains, are now recommended as first-line empirical treatment options providing high efficacy (reportedly > 90% in intention to treat analysis) even in high clarithromycin resistance settings. These include the bismuth quadruple, concomitant, sequential and hybrid therapies. Due to the rapid development of quinolone resistance, levofloxacin-based regimens should be reserved as second-line/rescue options. Adjunct use of probiotics has been proposed in order to boost eradication rates and decrease occurrence of treatment-related side effects. Molecular testing methods are currently available for the characterization of H. pylori therapeutic susceptibility, including genotypic detection of macrolide resistance and evaluation of the cytochrome P450 2C19 status known to affect the metabolism of proton pump inhibitors. In the future, use of these techniques may allow for culture-free, non-invasive tailoring of therapy for H. pylori infection.

Keywords: Helicobacter pylori; Antibiotic resistance; Bismuth-quadruple; Concomitant; Sequential; Probiotics

Core tip: Worldwide increase in prevalence of macrolide resistance has accounted for the failure of standard therapies for the treatment of Helicobacter pylori (H. pylori) infection. Bismuth quadruple, concomitant, sequential and hybrid therapies are now recommended as first-line empirical treatments providing improved efficacy in high clarithromycin resistance settings. As quinolone resistance is rapidly increasing, levofloxacin should be preferentially used in second-line/rescue therapies. There is increasing evidence that adjunct probiotic supplementation improves the therapeutic outcome and tolerability. Genotypic characterization of H. pylori susceptibility to therapy may allow for a tailored therapeutic approach in the future.