Published online Aug 7, 2014. doi: 10.3748/wjg.v20.i29.9898
Revised: January 27, 2014
Accepted: March 12, 2014
Published online: August 7, 2014
Treatment of Helicobacter pylori (H. pylori) infection is paramount for the management of prevalent gastrointestinal disorders including peptic ulcer disease and gastric cancer. Due to the wide increase in prevalence of H. pylori resistance to antibiotics, clarithromycin-based triple therapies are not any more suitable for unconditional empiric use, and should not be recommended, unless local resistance to this antibiotic is low (< 20%). Alternative strategies have been proposed to overcome the issue of increasing clarithromycin resistance, and some of them are already implemented in clinical practice. These comprise: (1) adoption of novel, more effective, empirical treatments: bismuth quadruple, sequential, non-bismuth quadruple (concomitant), dual-concomitant (hybrid), and levofloxacin-based regimens, the latter mainly designated as second-line/rescue options; (2) perspectives for a susceptibility-guided (tailored) therapeutic approach based on culture-free molecular testing methods; and (3) adjunct use of probiotics to improve eradication rates. The present article is aimed to provide a comprehensive overview of current and emerging strategies in the treatment of H. pylori infection, focusing on the challenge of antimicrobial resistance.
Core tip: Rising clarithromycin resistance has accounted for a dramatic decline in the efficacy of standard therapies for Helicobacter pylori (H. pylori) infection. Bismuth-quadruple, sequential, non-bismuth quadruple (concomitant), dual-concomitant (hybrid), and levofloxacin-based regimens are now recommended as preferred empirical treatments (> 90% efficacy). However, empiric treatment of H. pylori is likely to become more challenging as even these improved regimens are prone to the effect of antibiotic resistance. Individualized therapy appears as a reasonable future alternative, currently limited by the shortcomings of performing culture. Advances in the genotypic characterization of H. pylori therapeutic susceptibility are likely to revolutionize our approach to tailored treatment.