Published online Feb 14, 2014. doi: 10.3748/wjg.v20.i6.1517
Revised: October 29, 2013
Accepted: January 6, 2014
Published online: February 14, 2014
Helicobacter pylori is a highly successful bacterium with a high global prevalence and the infection carries significant disease burden. It is also becoming increasingly difficult to eradicate and the main reason for this is growing primary antibiotic resistance rates in a world where antibiotics are frequently prescribed and readily available. Despite knowing much more about the bacterium since its discovery, such as its genomic makeup and pathogenesis, we have seen declining treatment success. Therefore, clinicians today must be prepared to face one, two or even multiple treatment failures, and should be equipped with sufficient knowledge to decide on the appropriate salvage therapy when this happens. This article discusses the factors contributing to treatment failure and reviews the second and third-line treatment strategies that have been investigated. Established empiric second line treatment options include both bismuth based quadruple therapy and levofloxacin based triple therapy. Antibiotic testing is recommended prior to initiating third line treatment. In the event that antibiotic susceptibility testing is unavailable, third line treatment options include rifabutin, rifaximin and sitafloxacin based therapies.
Core tip: The reasons for treatment failure in Helicobacter pylori eradication need not always be due to antibiotic resistance; compliance to therapy and duration should always be evaluated. Choice of therapy need not strictly adhere to guidelines; clinicians should first explore the antibiotic resistance prevalence in their treatment population if possible. Third line therapy generally shows better eradication if it was based on antibiotic susceptibility tests, but this can be time-consuming and more costly. Empirical third-line therapies have yet to show satisfactory eradication rates although most studies generally have smaller study populations.