Treatment of Helicobacter pylori infection: Meeting the challenge of antimicrobial resistance

Table 1 Currently recommended regimens for the treatment of Helicobacter pylori infection

Treatment	Regimen	Comment
First-line therapies
Standard triple therapy	A PPI (standard dose, bid), amoxicillin (1 g, bid) and clarithromycin (500 mg, bid) for 14 d	Widely used option
		Only suitable for areas with < 20% incidence of cam resistance or as tailored treatment.
Bismuth-containing quadruple therapy	A PPI (standard dose, bid), bismuth (standard dose, qid) tetracycline (500 mg, qid) and metronidazole (500 mg, qid) for 10-14 d	Works independently to CAM and largely overcome MNZ resistance
		Valuable second-line treatment after failure of CAM-based regimens
		Patient-friendly monocapsule available
		Suitable for patients with penicillin allergy
		Non-availability of bismuth and/or tetracycline in some countries
Sequential therapy	A 5-d dual therapy with a PPI (standard dose, bid) and amoxicillin (1 g, bid) followed by a 5-d triple therapy with a PPI (standard dose, bid), clarithromycin (500 mg, bid) and metronidazole (500 mg, bid)	Widely evaluated option
		Probably effective in high resistance settings
		Questionable efficacy against double-resistant strains
		Less satisfactory results in more recent studies contacted outside Italy
Non-bismuth quadruple “Concomitant” therapy	A PPI (standard dose, bid), clarithromycin (500 mg, bid), amoxicillin (1 g, bid) and metronidazole (500 mg, bid) for 10 d	Probably effective in high resistance settings
		Larger number of pills compared to sequential and hybrid therapies
Hybrid therapy	A 7-d dual therapy with a PPI (standard dose, bid) and amoxicillin (1 g, bid) followed by a 7-d quadruple therapy with a PPI (standard dose, bid), amoxicillin (1 g, bid), clarithromycin (500 mg, bid) and metronidazole (500 mg, bid)	Probably effective in high resistance settings
		Few data available on its efficacy/safety
Second-line/rescue therapies
Levofloxacin-based triple therapy	A PPI (standard dose, bid), levofloxacin (500 mg, bid) and amoxicillin (1 g, bid) for 10 d	Works independently to CAM and MNZ
		Ineffective for high quinolone resistance settings (> 10%)
		Rapid development of quinolone resistance
Rifabutin-based triple therapy	A PPI (standard dose, bid), rifabutin (150 mg bid) and amoxicillin (1 g bid) for 14 d	Third or more rescue option
		Significant safety issues
		Development of mycobacterium resistance

PPI: Proton pump inhibitor; CAM: Clarithromycin; MNZ: Metronidazole.