What is the recommended secondary treatment regimen for Helicobacter pylori (H. pylori) infection?

From the Guidelines

The recommended secondary treatment regimen for Helicobacter pylori infection is a 10-day levofloxacin-amoxicillin triple therapy, which consists of a proton pump inhibitor (PPI) standard dose twice a day, levofloxacin 500 mg once a day or 250 mg twice a day, and amoxicillin 1000 mg twice a day. This regimen is typically used after failure of first-line therapy, such as standard triple therapy with amoxicillin, clarithromycin, and PPI 1. The choice of secondary treatment should be guided by local antibiotic resistance patterns and previous antibiotic exposure. According to the guidelines, if first-line therapy fails, a 10-day levofloxacin-amoxicillin triple therapy is recommended as second-line therapy 1.

Some key points to consider when choosing a secondary treatment regimen include:

• The prevalence of antibiotic resistance in the local population, which can affect the efficacy of certain regimens 1
• The patient's previous antibiotic exposure, which can also impact the effectiveness of certain treatments 1
• The potential for adverse effects and interactions with other medications, which should be carefully considered when selecting a regimen 1

It's also important to note that confirmation of eradication with a urea breath test, stool antigen test, or endoscopic biopsy should be performed at least 4 weeks after completion of therapy and after PPI discontinuation for at least 2 weeks. The most recent and highest quality study recommends the 10-day levofloxacin-amoxicillin triple therapy as a second-line option 1, which is a strong recommendation based on moderate-quality evidence.

From the Research

Secondary Treatment for H. pylori

The recommended secondary treatment regimen for Helicobacter pylori (H. pylori) infection is as follows:

• Bismuth-based quadruple therapy is the preferred second-line option 2
• Triple therapies based on levofloxacin and/or rifabutin mainly with combination of amoxicillin are options if multiple eradication failure occurs 2
• A combination therapy of metronidazole, omeprazole, and clarithromycin has been shown to be effective in curing H. pylori infection, with a cure rate of 88% 3
• Seven-day PPI-triple therapy with levofloxacin is very effective for H. pylori eradication, with an overall cure rate of 96% when combined with amoxicillin and 93% when combined with clarithromycin 4

Treatment Failure

In cases where the first-line treatment fails, the following options can be considered:

• Bismuth-based quadruple therapy 2
• Levofloxacin-based therapies 4
• Rifabutin-based rescue therapy, which has been shown to be effective in approximately 50% of cases after multiple previous eradication failures 5

Important Considerations

• Antibiotic resistance is a major cause of treatment failure, and antibiotic resistance testing may be necessary after multiple treatment failures 2
• Compliance and tolerance to the treatment regimen are crucial for successful eradication of H. pylori infection 3, 5, 4