Published online Jan 14, 2023. doi: 10.3748/wjg.v29.i2.390
Peer-review started: August 12, 2022
First decision: September 2, 2022
Revised: September 12, 2022
Accepted: December 1, 2022
Article in press: December 1, 2022
Published online: January 14, 2023
The eradication of Helicobacter pylori (H. pylori) is widely discussed given the high prevalence and incidence of its infection and since therapeutic failure is frequent establishing safe, effective, and accessible third-line and rescue therapies for patients in need of eradication is necessary in the management of such infection.
Even though eradication criteria and treatment algorithms for first-line and second-line therapy against H. pylori infection are well-established, there is no clear recommendation for third-line and rescue therapy in refractory H. pylori infection.
To evaluate the efficacy and safety of rescue therapies against refractory H. pylori infection and to establish safe, effective, and accessible third-line and rescue therapies for patients in need of eradication.
A systematic search of available rescue treatments for refractory H. pylori infection was conducted on the National Library of Medicine’s PubMed search platform based on Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Different descriptors were used throughout the study for maximization of the database, namely: Helicobacter pylori multidrug resistance and rescue therapy; H. pylori multiresistant and rescue treatment; Helicobacter pylori multidrug resistance and rescue treatment; Helicobacter pylori rescue therapy; Helicobacter pylori and third line treatment; and fourth line therapy and Helicobacter pylori. Upon reliable data detection and collection, a statistical analysis was performed to compare eradication rates both by intention to treat and per protocol, and adverse effects found in the different therapeutic approaches to assess their feasibility in clinical practice.
Twenty-eight studies were included in the analysis of mean eradication rates as rescue therapy, and 21 of these were selected for mean eradication rate analysis as third-line treatment. Rifabutin-, sitafloxacin-, levofloxacin-, and metronidazole-based triple therapies, bismuth quadruple therapy (BQT), BQT, three-in-one, Pylera® (BQT-Pylera), non-BQT, and susceptibility-guided therapy were assessed. Furthermore, sitafloxacin-based and rifabutin-based triple therapies achieved higher efficacy than other therapeutic approaches.
We managed to create a recommendation flowchart regarding rescue therapies in different situations, such as regions with previously known resistance to macrolides and in areas where bismuth is unavailable. These results can aid the clinical management of the H. pylori infection and furthermore prevent an increase in resistance rates to different antibiotics.
New clinical trials should be developed in order to assess the efficacy of regimens with different associations between antimicrobials and vonoprazan, based on the promising results reported from the comparison between conventional proton pump inhibitors and vonoprazan.