Helicobacter pylori eradication in West Asia: A review

Table 1 Primary Helicobacter pylori resistance to different antibiotics in West Asia

Country(R)	Year	Number of patients	Testing method	Amoxicillin	Metronidazole	Tetracycline	Clarithromycin	Other drugs
Iran[13]	1997-2000	70	DDM	1.4	33%	0%	1.4%
Iran[14]	2001-2004	135	DDM	3.7	36.3%	0.7%	3.7%
Iran[42]	2005	120	DDM	1.6	57.5%	0%	16.7%
Iran[58]	2005-2008	160	DDM	7.3	55.6%	38.1%	7.3%	Furazolidone: 4.5%
Iran[44]	2008	124	DDM	9.8	64.6%	0%	17.1%
Iran[43]	2010	42	DDM	2.4	40.5%	4.8%	14.3%	Ciprofloxacin: 2.4%
Iran[41]	2012	112	DDM	28	76.8%	18.6%	14.3%	Ciprofloxacin: 33%
								Rifampin: 28.6%
Iran[110]	2013	153	DDM	7.2	63.8%	-	26.5%	-
Turkey[45]	2003	87	DDM	-	-	-	27.5%
Turkey[16]	2004	110	DDM	-	-	-	48.2%
Turkey[17]	2006	92	DDM	-	-	-	40.5%
Turkey[111]	2007	61	DDM	-	-	-	16.4%
Turkey[63]	2012	61	DDM	0	42.6%	0%	21.3%	Levofloxain: 3.3%
Lebanon[112]	2002	54	DDM	0	29.5%	2%	4%
Bahrain[15]	1999	83	Epsilometer test	-	57%	-	33%
Saudi Arabia[59,61]	1988	71	DDM	-	38%	1.4%	-
Saudi Arabia[59,61]	1996	62	DDM	-	85.5%	0%	-
Saudi Arabia[59]	1998	63	DDM	-	78.5%	-	-
Saudi Arabia[60]	2002	223	DDM	1.3	80%	0.4%	4%
Saudi Arabia[62]	2008	46	DDM	0	69.5%	-	21%
UAE[113]	2010	26	E- test	-	-	-	19.2%
UAE[64]	2013	16	?	-	63%	-	-
Syria[114]	2012	130	FH	-	-	-	12.3%

DDM: Disk diffusion method; FH: Fluorescence in situ hybridization; UAE: United Arab Emirates.

Table 2 Randomized controlled trials for Helicobacter pylori eradication in Iran

Ref.	Type of patients	Type of triple therapy regimens	Number of patients in each study arm	Eradication rate (%)
				Per-protocol	Intention-to-treat
Mirzaee et al[21], 2012	NA	PAC-7, PAC-7 with yoghourt, PAC-7 with probiotic	34-34-34	61.3-73.1-64.5	NA
Sarkeshikian et al[24], 2013	PUD + NUD	OAC-10, OAAz-10	76-89	83-75	NA
Keshavarz et al[25], 2007	NUD	OAC-14, OAC[half dose]-14	80-80	89-88	83.7-85
Malekzadeh et al[19], 2003	Cancer Screening	OAC-7, OFT-4, OFT-7	45-41-42	42.1-20.6-29.4	35.5-17.1-23.8
Ahmad et al[82], 2013	PUD + NUD	OAF-7, OAF-7 with probiotic	33-33	70-90	70-90
Roghani et al[83], 2003	DU	OAF-14, OAF-14 [half dose]	63-61	88.9-67.9	76.2-62.3
Seyedmajidi et al[26], 2013	PUD	OAC-14, OABM-14, OCPen-14	110-110-110	90.8-56-87	80.9-50.9-79
Ghadir et al[81], 2011	PUD	OAF-14, OABF-14	43-43	61.1-85.3	51.2-67.4
Taghavi et al[27], 2009	NUD	OAC-14, O.Co.Dox.-14, OABF-14	53-67-69	70-63-56	66-61-49
Sotudehmanesh et al[52], 2001	DU	RBTM-14, RBTM-21, OBCT-14	74-73-76	73-71-88	68-68-80
Malekzadeh et al[49], 2000	DU	RABM-14, RABF-14	53-53	56-82	55-75
Khatibian et al[48], 2007	PUD	OABM-14, OABF-14, OABF (first week) M (second week)	107-104,103	83.1-95.2,95.3	74.5-87,86.6
Shidfar et al[51], 2012	NS	OABM-14, OABM-14 + Lycopen	27-27	68-77.8	62.9-77.8
Mousavi et al[50], 2006	PUD, NUD	OABM-14, OAzBM-7	65-64	75.7-78.1	70.4-74.1
Agah et al[47], 2009	NUD	OABM-14, OABAz[first 7 d]-14	30-30	69-68	NA
Mirbagheri et al[20], 2006	NUD	OAC-7, OABM-10, O.Am.BM-10	120-120-120	91.1-85.5-92.8	84.1-86.6-80.8
Shavakhi et al[84], 2013	PUD	OABC-14, OABC-14 with probiotic	90-90	84.4-82.1	81.1-76.6
Fakheri et al[79], 2001	DU	OABC-14, OABF-14	55-63	90-90	85-84
Daghaghzadeh et al[78], 2007	PUD, NUD	OABF-7, OABF-14	78-78	84.8-82.6	71.8-73.1
Fakheri et al[80], 2004	DU	OAF-14, OABF(low dose F)-14, OABF-14	50-50-50	54-72-92	54-72-92
Aminian et al[22], 2010	Dyspepsia	OA-MC-10, OABM-14, OAC-10, OCCip[first 7 d]-14	107-107-107	81.1-85.7-90.7-70	80.4-84-90.7-65
Fakheri et al[69], 2012	DU	PA-CT-10, PA-BF[7]-14	148-148	89.1-88.7	83.7-80.4
Sardarian et al[68], 2013	DU	PA-CT-10, PA-CT-14 (HYBRID)	210-210	79.9-92.9	76.7-89.5
Riahizadeh et al[23], 2010	PUD, NUD	OAB-MF-10, OAC-10, OAB-CF-10	107-106-106	91.3-90.4-88.7	78.5-81.1-82

O: Omeprazole; R: Rabeprazole; A: Amoxicillin; C: Clarithromycine; Az: Azithrmycine; Cip: Ciprofluxacin; Pen: Penbactam; Of: Ofloxaciline; Co: Co-amoxicalv; Dox: Doxycylcine; F: Furazolidone; T: Tetracycline; M: Metronidazole; B: Bismuth subcitrate; NA: not available; PUD: Peptic ulcer disease; NUD: Non-ulcer dyspepsia.

Table 3 Randomized controlled trials for Helicobacter pylori eradication in Turkey

Ref.	Type of patients	Type of triple therapy regimens	Number of patients in each study arm	Eradication rate (%)
				Per-protocol	Intention-to-treat
Aydin et al[29], 2007	PUD + NUD	PAC-14, PAC-7	40-40	73.5-47.1	67.6-44.4
Yaşar et al[33], 2010	Dyspepsia	PAC-14, PAC-14 with probiotic	38-38	53-66	53-66
Uygun et al[32], 2004	Dyspepsia	LAC-14, PAC-14	45-45	69.2-70	62.2-60
Sezikli et al[31], 2012	NUD	LAC-14, LAT-14	40-40	47.4-39.3	45-37.5
Aladağ et al[28], 2005	DU	OAC-14, PAC-14	64-62	90.6-93.5	90.6-93.5
Erçin et al[75], 2011	DU	LALevo-7, LALevo-14	51-40	34.1-72.7	27-65
Seven et al[76], 2004	PUD-NUD	OALevo-10, OALevo-10[half dose]	50-60	72.7-60	72.7-60
Gumurdulu et al[30], 2004	PUD	OAC-7 , OAC-14, OBTM-10	53-59-52	NA	24.5-40.6-61.5
Alkim et al[34], 2011	PUD + NUD	OAC-14, LAC-14, RAC-14, PAC-14, EAC-14, RBAC-14	66-66-66-66-66-66	65.6-72.1-84.4-62.5-60.3-85.7	63.6-66.7-81.8- 60.6-57.6-81.8
Songür et al[35], 2009	PUD, NUD	LAC-14, LMT-10, LBMT-10, RLBMT-10	113-115-119-117	35.6-64.4-54.9-64.6	32.7-60-47.1-57.3
Uygun et al[36], 2007	NUD	LAC-14, LBMT-14	120-120	62.7-82.3	57.5-70
Kadayifci et al[56], 2012	NUD	EABT-14, EAMT-14	100-100	89.7-80.4	79-74
Sezgin et al[55], 2006	PUD + NUD	RBMT-14, PBMT-14	42-40	61.9-55	61.9-55
Uygun et al[57], 2007	NUD	RBAT-14, RBAC-14, RBMT-14	100-100-100	64.4-66.2-58.9	58-59-56
Akyildiz et al[53], 2009	PUD + NUD	RBAT-14, RBADox-14	58-57	40.8-45.7	34.5-36.8
Köksal et al[54], 2013	Dyspepsia	OBTM-14 ,	45 - 45	86.8-90.1	73.3-89.9
		OBTM-14[Optimal dose]
Nadir et al[37], 2011	Dyspepsia	LA-MT-14, LAC-14,	144-138	77.6-53.6	72.2-52.5
Yakut et al[71], 2010	Dyspepsia	PA-MT-10, RaBAC-14	108-75	88-95	88-95
Uygun et al[39], 2008	NUD	PA-MT-14, PAC-14	150-150	80.1-63	72.6-58
Cetinkaya et al[70], 2010	NUD	PA-MT-14, PA-TM-14 (HYBRID)	56-56	83.6-81.4	82.1-78.5
Polat et al[38], 2011	NUD	E-A-[first 7 d]-LevoM-[last 7 d]-14, EAC-14	75-75	90-57	86.6-50.6

O: Omeprazole; E: Esomeprazole; B: Bismuth; Ra: Ranitidine; A: Amoxicillin; C: Clarithromycine; L: Lansoprazole; P: Pantoprazole; T: Tetracycline; M: Metronidazole; R: Rabeprazole; Levo: Levofloxacine; NA: Not available; PUD: Peptic ulcer disease; NUD: Non-ulcer dyspepsia.

Table 4 Randomized controlled trials for Helicobacter pylori eradication in other West Asian countries

Ref.	Type of patients	Type of triple therapy regimens	Number of patients in each study arm	Eradication rate (%)
				Per-protocol	Intention-to-treat
Sharara et al[77], 2004	Dyspepsia	RAG-7, R[half dose]AG-7	52-52	92-83	92-83

A: Amoxicillin; C: Clarithromycine; R: Rabeprazole; G: Gatifloxacine; Tin: Tinidazole; E: Esomeprazole; T: Tetracycline; PUD: Peptic ulcer disease; NUD: Non-ulcer dyspepsia.

Table 5 Recommended treatment regimens for Helicobacter pylori eradication in West Asia

First-line therapeutic options:

10-d Bismuth-Furazolidone Quadruple therapy:

Pantoprazole 40 mg BD + Amoxicillin 1 g BD + Bismuth 240 mg BD for 10 d; Metronidazole 500 mg BD just over the first 5 d and Furazolidone 200 mg BD over the second 5 d

14-d Clarithromycin-containing Hybrid therapy:

Pantoprazole 40 mg BD + Amoxicillin 1 g BD for 14 d and Clarithromycin 500 mg BD + Tinidazole 500 mg BD just over the last 7 d

14-d Omeprazole-Bismuth-Tetracycline-Metronidazole, if:

Omeprazole 20 mg BD + Bismuth 240 mg BD + Tetracycline 500 mg QID + Metronidazole 500 mg TDS for 14 d

Second-line therapeutic options:

14-d Omeprazole-Bismuth-Tetracycline-Furazolidone:

Omeprazole 20 mg BD + Bismuth 240 mg BD + Tetracycline 500 mg BD + Furazolidone 200 mg BD (if Furazolidone is not used as first-line)

14-d Ranitidine-Bismuth-Tetracycline-Metronidazole:

Ranitidine-Bismuth 400 mg BD + Tetracycline 500 mg BD + Metroidazole 500 mg BD

7-d Rabeprazole-Amoxicillin-Gatifloxacin:

Rabeprazole 20 mg BD + Amoxicillin 1 g BD + Gatifloxacin 400 mg Daily

14-d Omeprazole-Bismuth-Azithromycin-Ofloxacin:

Omeprazole 20 mg BD + Bismuth 240 mg BD + Azithromycin 250 mg BD + Ofloxacin 200 mg BD

Third-line therapeutic options:

The optimal regimen must be chosen according to the pattern of antibiotic susceptibility of H. pylori1

¹Rifabutin-containg triple therapy may also be a suitable option[100,101]. BD: Twice a day; TDS: Three times a day; QID: Four times a day; H. pylori: Helicobacter pylori.