Department of Medicine, Division of Gastroenterology, McGill University Health Center, Montreal, Québec, Canada.
Department of Medicine, Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
Gastroenterology. 2019 Jul;157(1):44-53. doi: 10.1053/j.gastro.2019.04.011. Epub 2019 Apr 15.
Increasing resistance to antibiotics worldwide has adverse effects on the effectiveness of standard therapies to eradicate Helicobacter pylori infection. We reviewed guidelines developed by expert groups in Europe, Canada, and the United States for the treatment of H pylori infection. We compared the recommendations of these guidelines, reconciled them, and addressed the increasing resistance of H pylori to antibiotic therapy regimens. The guidelines recommend bismuth quadruple therapy for first-line treatment, replacing clarithromycin-based triple therapy. There is consensus for concomitant 4-drug therapy as an alternative, especially when bismuth is not available. When therapy is unsuccessful, it is likely due to resistance to clarithromycin, levofloxacin, and/or metronidazole; these drugs, if used previously, should be avoided in subsequent eradication attempts. Second-line therapies should be bismuth quadruple therapy or levofloxacin triple therapy, depending on suspected resistance, reserving rifabutin-based triple and high-dose dual amoxicillin proton pump inhibitor therapy for subsequent treatment attempts. The increasing resistance of H pylori to antibiotic therapy necessitates local availability of susceptibility tests for individuals, and establishment of regional and national monitoring programs to develop evidence-based locally relevant eradication strategies. Further studies into the development of more easily accessible methods of resistance testing, such as biomarker analysis of stool samples, are required. Options under investigation include substituting vonoprazan for proton pump inhibitors, adding probiotics, and vaccine development. Narrow-spectrum antibiotics and new therapeutic targets could be identified based on genomic, proteomic, and metabolomic analyses of H pylori.
全球范围内抗生素耐药性的增加对根除幽门螺杆菌感染的标准治疗效果产生了不利影响。我们回顾了欧洲、加拿大和美国专家组制定的治疗幽门螺杆菌感染的指南。我们比较了这些指南的建议，对其进行了协调，并讨论了幽门螺杆菌对抗生素治疗方案耐药性的增加。这些指南建议铋四联疗法作为一线治疗，取代基于克拉霉素的三联疗法。同时使用 4 种药物治疗作为替代方案具有共识，尤其是在没有铋的情况下。如果治疗不成功，很可能是由于对克拉霉素、左氧氟沙星和/或甲硝唑的耐药性所致；如果之前使用过这些药物，应避免在随后的根除尝试中使用。二线治疗应采用铋四联疗法或左氧氟沙星三联疗法，具体取决于疑似耐药性，将利福布汀三联疗法和高剂量双联阿莫西林质子泵抑制剂疗法保留用于随后的治疗尝试。幽门螺杆菌对抗生素治疗的耐药性增加需要在个体中进行药敏试验的本地可用性，并建立区域和国家监测计划，以制定基于证据的、具有本地相关性的根除策略。需要进一步研究开发更易于获得的耐药性检测方法，例如粪便样本的生物标志物分析。正在研究的方案包括用沃诺拉赞替代质子泵抑制剂、添加益生菌和疫苗开发。可以基于幽门螺杆菌的基因组、蛋白质组和代谢组分析来确定窄谱抗生素和新的治疗靶点。
