What is the most effective second-line Helicobacter pylori (H. pylori) eradication therapy in Australia?

From the Guidelines

The most effective second-line H. pylori eradication therapy in Australia is a bismuth-containing quadruple therapy or a levofloxacin-containing triple therapy, with the choice of regimen depending on local resistance rates and patient factors, as recommended by the most recent guidelines 1.

Key Considerations

• The choice of second-line therapy should be guided by the results of antibiotic susceptibility testing, if available, and consideration of local resistance rates 1.
• Bismuth-containing quadruple therapy is a recommended option for second-line treatment, and includes bismuth subsalicylate (or bismuth subcitrate), a proton pump inhibitor (PPI), tetracycline, and metronidazole for 14 days 1.
• Levofloxacin-containing triple therapy is also a recommended option, but its use should be limited to areas with low levofloxacin resistance rates (<15%) or when the H. pylori strain is known to be sensitive to it 1.

Treatment Regimens

• Bismuth-containing quadruple therapy: bismuth subsalicylate 120mg four times daily, omeprazole 20mg twice daily, tetracycline 500mg four times daily, and metronidazole 400mg three times daily for 14 days.
• Levofloxacin-containing triple therapy: levofloxacin 500mg daily, amoxicillin 1000mg twice daily, and a PPI for 14 days.

Important Notes

• Before starting second-line therapy, it's essential to confirm treatment failure with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing initial therapy and after PPI cessation for 2 weeks 1.
• Antibiotic susceptibility testing should be considered if available, especially in patients with multiple treatment failures 1.

From the Research

Second-Line H. pylori Eradication Therapy in Australia

The most effective second-line H. pylori eradication therapy in Australia is not explicitly stated in the provided studies. However, the following points can be considered:

• A study from 2016 2 found that the levofloxacin, bismuth, amoxicillin, and esomeprazole (LBAE) regimen achieved eradication rates of 73.5% in intention-to-treat and 78.5% in per-protocol analyses.
• Another study from 2012 3 found that a 14-day levofloxacin/amoxicillin/esomeprazole triple therapy achieved eradication rates of 93.6% in per-protocol analysis and 86.3% in intention-to-treat analysis.
• A 2011 study 4 found that a modified sequential therapy with a proton pump inhibitor and amoxicillin for 14 days with clarithromycin and metronidazole added as a quadruple (hybrid) therapy for the final 7 days achieved an eradication rate of 99.1% in per-protocol analysis.
• A pooled analysis from 2001 5 found that ranitidine bismuth-based triple therapy and quadruple therapy seemed to be the most effective re-treatment therapies.
• A 2020 systematic review and network meta-analysis 6 compared the relative efficacy of 16 second-line H. pylori eradication regimens and found that quinolone-based sequential therapy, quinolone-based bismuth quadruple therapy, and bismuth quadruple therapy were significantly superior to other regimens.

Key Findings

• The LBAE regimen achieved moderate eradication rates, but its efficacy was reduced in populations with high levofloxacin resistance 2.
• The levofloxacin/amoxicillin/esomeprazole triple therapy achieved high eradication rates, but its efficacy was also reduced in the presence of fluoroquinonole resistance 3.
• The modified sequential therapy achieved high eradication rates, but further studies are needed to confirm these findings in different populations 4.
• The choice of second-line therapy may depend on the presence of antibiotic resistance and the specific population being treated 5, 6.

Considerations

• The presence of antibiotic resistance, such as levofloxacin resistance, can significantly reduce the efficacy of second-line therapies 2, 3.
• The choice of second-line therapy should be guided by the specific population being treated and the presence of antibiotic resistance 5, 6.
• Further studies are needed to confirm the findings of these studies and to determine the most effective second-line therapies in different populations.