Gisbert Javier P, Calvet Xavier
Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IP), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
Clin Exp Gastroenterol. 2012;5:23-34. doi: 10.2147/CEG.S25419. Epub 2012 Mar 13.
Traditional standard triple therapy for Helicobacter pylori (H. pylori) infection (proton pump inhibitor-clarithromycin-amoxicillin) can easily be converted to non-bismuth quadruple (concomitant) therapy by the addition of a nitroimidazole twice daily.
To critically review evidence on the role of non-bismuth quadruple therapy (proton pump inhibitor-clarithromycin-amoxicillin-nitroimidazole) in the treatment of H. pylori infection.
Bibliographical searches were performed in MEDLINE and relevant congresses up to December 2011. We performed a meta-analysis of the studies evaluating the concomitant therapy, and of the randomized controlled trials comparing the concomitant and the standard triple therapy.
A meta-analysis of 19 studies (2070 patients) revealed a mean H. pylori cure rate (intention-to-treat) of 88% (95% confidence interval from 85% to 91%) for non-bismuth quadruple therapy. We performed a meta-analysis of the randomized controlled studies comparing the concomitant (481 patients) and the standard triple therapy (503 patients). The former was more effective than the latter: 90% versus 78% (intention-to-treat analysis). Results were homogeneous (I(2) = 0%). The odds ratio for this comparison was 2.36 (95% confidence interval from 1.67 to 3.34). A tendency toward better results with longer treatments (7-10 days versus 3-5 days) has been observed, so it seems reasonable to recommend the length of treatment achieving the highest cure rates (10 days). Clarithromycin resistance may reduce the efficacy of non-bismuth quadruple therapy, although the decrease in eradication rates seems to be far lower than in standard triple therapy. Experience with the non-bismuth quadruple therapy in patients with metronidazole-resistant strains is still very limited.
Non-bismuth quadruple (concomitant) therapy appears to be an effective, safe, and well-tolerated alternative to triple therapy and is less complex than sequential therapy. Therefore, this regimen appears well suited for use in settings where the efficacy of triple therapy is unacceptably low.
幽门螺杆菌（H. pylori）感染的传统标准三联疗法（质子泵抑制剂-克拉霉素-阿莫西林）通过每日两次添加硝基咪唑可轻松转换为非铋剂四联（联合）疗法。
批判性地回顾关于非铋剂四联疗法（质子泵抑制剂-克拉霉素-阿莫西林-硝基咪唑）在治疗幽门螺杆菌感染中作用的证据。
在MEDLINE及截至2011年12月的相关会议上进行文献检索。我们对评估联合疗法的研究以及比较联合疗法和标准三联疗法的随机对照试验进行了荟萃分析。
对19项研究（2070例患者）的荟萃分析显示，非铋剂四联疗法的幽门螺杆菌平均治愈率（意向性治疗）为88%（95%置信区间为85%至91%）。我们对比较联合疗法（481例患者）和标准三联疗法（503例患者）的随机对照研究进行了荟萃分析。前者比后者更有效：意向性治疗分析中分别为90%和78%。结果具有同质性（I² = 0%）。该比较的优势比为2.36（95%置信区间为1.67至3.34）。已观察到治疗时间较长（7 - 10天对比3 - 5天）有取得更好结果的趋势，因此推荐达到最高治愈率的治疗时长（10天）似乎是合理的。克拉霉素耐药可能会降低非铋剂四联疗法的疗效，尽管根除率的下降似乎远低于标准三联疗法。非铋剂四联疗法在甲硝唑耐药菌株患者中的经验仍然非常有限。
非铋剂四联（联合）疗法似乎是三联疗法有效、安全且耐受性良好的替代方案，并且比序贯疗法更简单。因此，该方案似乎非常适合用于三联疗法疗效低得不可接受的情况。
