From the Guidelines
Multiple rounds of quadruple therapy for H. pylori infection are possible but should be approached cautiously, with a preference for using different antibiotics in subsequent rounds rather than repeating the same regimen, as recommended by the most recent guidelines 1. When considering multiple rounds of treatment, it's essential to confirm H. pylori eradication with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and while off proton pump inhibitors for 2 weeks.
- The choice of antibiotics for subsequent rounds should be guided by suspected resistance patterns and antibiotic usage history, avoiding repeated use of macrolides and fluoroquinolones due to high resistance rates 1.
- Alternative antibiotics such as amoxicillin, tetracycline, and rifabutin can be used in repeated regimens due to their low primary and secondary resistance rates 1.
- Age, comorbidities, and concomitant medications should also be considered when selecting subsequent therapy, factoring into shared decision-making 1.
- Each subsequent treatment attempt has diminishing success rates, with first-line therapy achieving 70-90% eradication, second-line 60-80%, and third-line below 60% 1.
- Standard quadruple therapy typically includes a proton pump inhibitor, bismuth subsalicylate, tetracycline, and metronidazole for 10-14 days, with alternative regimens available, such as concomitant non-bismuth quadruple therapy or levofloxacin-based regimens 1.
From the Research
Multiple Rounds of Quadruple Therapy for Pylori
- The effectiveness of repeated quadruple therapy in Helicobacter pylori infection after failure of second-line quadruple therapy has been studied 2.
- A study found that a retrial of quadruple therapy before use of a third-line therapy may be safe and effective for patients who fail to respond to second-line quadruple therapy, with an eradication rate of 75.0% at per-protocol analysis 2.
- Another study compared two tetracycline-based regimens for quadruple rescue therapy after first and second line failure for Helicobacter pylori treatment, and found that the association minocycline/rifabutin seems to have a synergic effect and a good therapeutic outcome in patients who have failed at least two previous regimens 3.
- Current guidelines recommend bismuth quadruple therapy as the best initial empiric treatment, and concomitant, sequential and hybrid therapies are remarkable bismuth-free quadruple options 4.
- The use of levofloxacin-, rifabutin-, furazolidone- and sitafloxacin-containing regimens as salvage options has also been suggested 4.
- However, the feasibility and cost-effectiveness of universal pre-treatment susceptibility testing warrants further evaluation, and molecular testing methods promise convenient characterization of H. pylori antibiotic susceptibility 4.
- A study also found that triple therapy with high-dose proton-pump inhibitor, amoxicillin, and doxycycline is useless for Helicobacter pylori eradication in patients with multidrug-resistant H. pylori 5.