Published online Nov 15, 2014. doi: 10.4291/wjgp.v5.i4.392
Revised: April 15, 2014
Accepted: July 17, 2014
Published online: November 15, 2014
Helicobacter pylori (H. pylori) is a major human pathogen associated with significant morbidity and mortality. However, after decades of efforts, treatment of H. pylori remains a challenge for physicians, as there is no universally effective regimen. Due to the rising prevalence of antimicrobial resistance, mainly to clarithromycin, efficacy of standard triple therapies has declined to unacceptably low levels in most parts of the world. Novel regimens, specifically experimented to improve the therapeutic outcome against antibiotic-resistant H. pylori strains, are now recommended as first-line empirical treatment options providing high efficacy (reportedly > 90% in intention to treat analysis) even in high clarithromycin resistance settings. These include the bismuth quadruple, concomitant, sequential and hybrid therapies. Due to the rapid development of quinolone resistance, levofloxacin-based regimens should be reserved as second-line/rescue options. Adjunct use of probiotics has been proposed in order to boost eradication rates and decrease occurrence of treatment-related side effects. Molecular testing methods are currently available for the characterization of H. pylori therapeutic susceptibility, including genotypic detection of macrolide resistance and evaluation of the cytochrome P450 2C19 status known to affect the metabolism of proton pump inhibitors. In the future, use of these techniques may allow for culture-free, non-invasive tailoring of therapy for H. pylori infection.
Core tip: Worldwide increase in prevalence of macrolide resistance has accounted for the failure of standard therapies for the treatment of Helicobacter pylori (H. pylori) infection. Bismuth quadruple, concomitant, sequential and hybrid therapies are now recommended as first-line empirical treatments providing improved efficacy in high clarithromycin resistance settings. As quinolone resistance is rapidly increasing, levofloxacin should be preferentially used in second-line/rescue therapies. There is increasing evidence that adjunct probiotic supplementation improves the therapeutic outcome and tolerability. Genotypic characterization of H. pylori susceptibility to therapy may allow for a tailored therapeutic approach in the future.