Letters To The Editor
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 14, 2016; 22(38): 8638-8640
Published online Oct 14, 2016. doi: 10.3748/wjg.v22.i38.8638
Role of concomitant therapy for Helicobacter pylori eradication: A technical note
Giuseppe Losurdo, Floriana Giorgio, Andrea Iannone, Mariabeatrice Principi, Michele Barone, Alfredo Di Leo, Enzo Ierardi
Giuseppe Losurdo, Floriana Giorgio, Andrea Iannone, Mariabeatrice Principi, Michele Barone, Alfredo Di Leo, Enzo Ierardi, Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, 70124 Bari, Italy
Author contributions: Losurdo G, Di Leo A and Ierardi E conceived the article; Losurdo G and Ierardi E wrote the article; Giorgio F, Iannone A, Principi M and Barone M collected the data; all Authors read and approved the final version of the manuscript.
Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Enzo Ierardi, Professor, Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy. ierardi.enzo@gmail.com
Telephone: +39-80-5594034 Fax: +39-80-5593088
Received: July 11, 2016
Peer-review started: July 13, 2016
First decision: August 19, 2016
Revised: August 27, 2016
Accepted: September 12, 2016
Article in press: September 12, 2016
Published online: October 14, 2016

We read with interest the recent meta-analysis by Lin et al who evaluated the effectiveness of concomitant regimen for Helicobacter pylori (H. pylori) in Chinese regions. They found that 7-d concomitant regimen is undoubtedly superior to 7-d triple therapy (91.2% vs 77.9%, P < 0.0001). However, it is a common belief that a triple therapy lasting 7 d should be definitively removed from the clinical practice for its ineffectiveness. Only its prolongation to 14 d may give satisfactory success rate. Thus, the assessment of an old and outdated treatment versus a more recent and successful one does not seem to bring novel and useful information. Moreover, a 7-d duration has not been ascertained for concomitant regimen, as main guidelines recommend a 10-d schedule for this scheme. Therefore, only studies comparing 10-d concomitant versus 14-d triple seem to be appropriate according to current Guidelines and would clarify which regimen is the most suitable worldwide. Additionally, in this meta-analysis concomitant and sequential therapy showed similar performances, despite it is common opinion that sequential is more prone than concomitant therapy to fail when metronidazole resistance occurs, and China is characterized by high rate of resistance to this antibiotic. None of the included studies evaluated a priori antibiotic resistances, and the lack of this detail hampers the unveiling of this apparent contradiction. In conclusion, the lack of the evaluation of the quality of included trials as well as their high heterogeneity constitute a burdensome limit to draw solid conclusions in this meta-analysis. On the bases of these considerations and the low number of examined trials, we believe that further studies and the knowledge of antibiotic resistances will support with high quality evidence which is the best regimen and its optimal duration.

Keywords: Helicobacter pylori, Eradication, Sequential, Concomitant, Triple therapy, Antibiotic resistances

Core tip: Concomitant therapy is one of the most effective first line regimen for Helicobacter pylori eradication. The comparison with other regimens (sequential or triple) in a selected geographical region (China in this case) implies several issues. The low number of included studies, the lack of quality evaluation and the high heterogeneity may undermine the strength of a meta-analysis. Therefore, further studies are needed to prove which is the best first line eradication treatment in China, according to the geographical differences in antibiotic resistances.