Huang Hsiang Tso, Wang Hsin-Ming, Yang Shih-Cheng, Tai Wei-Chen, Liang Chih-Ming, Wu Keng-Liang, Lee Chen-Hsiang, Chuah Seng-Kee
Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niao-Song District, Kaohsiung 833, Taiwan,
Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niao-Song District, Kaohsiung 833, Taiwan.
Infect Drug Resist. 2018 Oct 30;11:2073-2080. doi: 10.2147/IDR.S185511. eCollection 2018.
To assess the efficacy of amoxicillin, tetracycline, high-dose metronidazole, and a proton-pump inhibitor for third-line eradication.
We enrolled 70 consecutive patients who had registered, failed to respond to two rounds of eradication, and undergone endoscopy for culture. Seven patients were lost to follow-up. Patients were treated according to the results of antibiotic-susceptibility testing reports (cultured group, n=39). Those who failed the culture were prescribed 14-day quadruple therapy containing esomeprazole 40 mg twice daily, amoxicillin 1 g twice daily, tetracycline 500 mg four times daily, and metronidazole 500 mg three times daily (empirical group, n=24). A follow-up urea breath test was performed 8 weeks later.
Antibiotic-resistance rates were 79.5% (clarithromycin), 94.9% (levofloxacin), 66.7% (metronidazole), 2.6% (amoxicillin), and 0 (tetracycline). Eradication rates attained by the cultured and empirical group were 89.7% (95% CI 72.7%-97.1%) and 58.3% (95% CI 36.6%-77.9%) in per-protocol analysis (=0.004) and 81.4% (95% CI 66.6%-91.6%) and 51.8% (95% CI 31.9%-71.3%) in intention-to-treat analysis (=0.014), respectively. Culture-guided therapy was the only clinical factor influencing the efficacy of eradication (OR 0.16, 95% CI 0.04-0.60; =0.006). Despite the high metronidazole-resistance rate (66.7%) after two treatment failures, the eradication rate in patients with this condition was 84%.
Empirical 14-day modified quadruple therapy is not acceptable as an alternative third-line rescue treatment. The success rate of third-line susceptibility-guided treatment was near 90%. This report is valuable as a reminder to medical practitioners that rather than a try-and-see approach, susceptibility-guided therapy should always be considered whenever possible for patients who have undergone several treatment failures.
评估阿莫西林、四环素、高剂量甲硝唑及质子泵抑制剂用于三线根除治疗的疗效。
我们纳入了70例连续登记的患者，这些患者对两轮根除治疗均无反应且接受了内镜检查以进行培养。7例患者失访。根据抗生素敏感性测试报告结果对患者进行治疗（培养组，n = 39）。培养失败的患者给予14天的四联疗法，即埃索美拉唑40 mg，每日2次；阿莫西林1 g，每日2次；四环素500 mg，每日4次；甲硝唑500 mg，每日3次（经验组，n = 24）。8周后进行随访尿素呼气试验。
抗生素耐药率分别为：克拉霉素79.5%、左氧氟沙星94.9%、甲硝唑66.7%、阿莫西林2.6%、四环素0%。在符合方案分析中，培养组和经验组的根除率分别为89.7%（95%CI 72.7%-97.1%）和58.3%（95%CI 36.6%-77.9%）（P = 0.004）；在意向性分析中分别为81.4%（95%CI 66.6%-91.6%）和51.8%（95%CI 31.9%-71.3%）（P = 0.014）。培养指导治疗是影响根除疗效的唯一临床因素（OR 0.16，95%CI 0.04 - 0.60；P = 0.006）。尽管在两次治疗失败后甲硝唑耐药率较高（66.7%），但该情况下患者的根除率为84%。
经验性14天改良四联疗法作为替代性三线挽救治疗不可接受。三线药敏指导治疗的成功率接近90%。本报告对于提醒医学从业者很有价值，即对于经历多次治疗失败的患者，应尽可能考虑药敏指导治疗，而非试错法。
