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What is the self-directed learning issue that was identified in your oral presentation?

 

Triple vs quadruple treatment against H.pylori

Research the self-directed learning issue and provide a summary of your findings which is fully supported by appropriate, scholarly, EBM references.

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Helicobacter pylori eradication is often difficult, and it requires the use of a combination therapy to eradicate the bacteria successfully. The combination therapy usually includes a proton pump inhibitor or a bismuth with two or three antibiotics to attain a high rate of eradication and lower the chances of failure as a result of antibiotic resistance (Chey, Leontiadis, Howden, & Moss, 2017). The two used combination therapies are Triple and Quadruple therapy.

Triple Therapy

The traditional Triple therapy regimen includes a 14-day course with: a proton pump inhibitor (PPI), Clarithromycin 500 mg, and Amoxicillin 1 gm or Metronidazole 500 mg, twice a day if allergic to penicillin (Chey et al., 2017). The regimen achieves an eradication rate of only 75% or more, and Clarithromycin resistance has been in the rise. It is therefore restricted for use in areas with a low resistance to clarithromycin less than 15 % and patients with no history of exposure to macrolides (Nyssen et al., 2015).

Levofloxacin triple therapy includes (PPI + levofloxacin + amoxicillin) is used as a second-line treatment when quadruple treatment fails and is considered a rescue therapy (Chen et al., 2016).

Quadruple Therapy

Quadruple therapy is more complicated but achieves better eradication rates than the Triple therapy. There are two types of quadruple therapy, mainly Bismuth quadruple and non-bismuth quadruple therapy. Bismuth quadruple therapy includes a regimen for 14 days with Bismuth subsalicylate two tablets four times daily, PPI twice daily, Tetracycline 500 mg four times a day, and Metronidazole 500 mg three times a day or Tinidazole 500 mg (Zagari, Rabitti, Eusebi, & Bazzoli, 2018). The Bismuth quadruple regimen is increasingly being used as first-line therapy due to its high efficacy. It is the regimen of choice in areas with high resistance of clarithromycin and metronidazole.

Non-bismuth quadruple regimen includes a PPI, Clarithromycin, Amoxicillin, and Metronidazole or Tinidazole for 10 days. The non-bismuth regimen has two approaches, mainly sequential and concomitant therapy, which were developed to overcome the Clarithromycin resistance (Zagari et al., 2018). In sequential treatment, Amoxicillin is taken for 5 days and then replaced by Clarithromycin and Metronidazole for the next 5 days (Nyssen et al., 2015). However, Clarithromycin and metronidazole resistance has affected the efficacy of the sequential regimen.

In concomitant therapy, Clarithromycin, amoxicillin, and metronidazole are taken together. Studies have revealed that concomitant therapy achieves an eradication rate of about 80% in patients with clarithromycin resistance strains, and it appears not to be affected by clarithromycin resistance (Zagari et al., 2018). Nonetheless, concomitant therapy has a weakness as it loses efficacy when there are H. pylori strains with resistance to both clarithromycin and metronidazole.

Algorithm for H.pylori Eradication

1.    The first line: 14-day Triple therapy containing Clarithromycin only in areas with low-prevalence of clarithromycin resistance or no previous macrolide exposure OR Bismuth quadruple therapy/concomitant therapy (Chey, Leontiadis, Howden & Moss, 2017).

2.    Second line: PPI-Amoxicillin-Levofloxacin triple therapy OR Bismuth quadruple therapy.

Conclusion

Triple therapy is least preferred and is only recommended in areas with low clarithromycin resistance or in patients with no previous macrolide exposure. Quadruple therapy, especially Bismuth quadruple, is preferred to triple therapy in areas with known high resistance to antibiotics. However, sequential therapy is not recommended due to clarithromycin resistance. However, levofloxacin-triple therapy is used as an alternative when quadruple therapy fails.

 

REFERENCES

Chey, W. D., Leontiadis, G. I., Howden, C. W., & Moss, S. F. (2017). ACG clinical guideline: treatment of Helicobacter pylori infection. The American journal of gastroenterology112(2), 212.

Chen, P. Y., Wu, M. S., Chen, C. Y., Bair, M. J., Chou, C. K., Lin, J. T., Liou, J.M., & Taiwan Gastrointestinal Disease and Helicobacter Consortium. (2016). Systematic review with meta‐analysis: the efficacy of levofloxacin triple therapy as the first‐or second‐line treatments of Helicobacter pylori infection. Alimentary pharmacology & therapeutics44(5), 427-437.

Nyssen, O. P., McNicholl, A. G., Megraud, F., Savarino, V., Oderda, G., Fallone, C. A., Fischbach, L., Bazzoli, F., & Gisbert, J. P. (2016). Sequential versus standard triple first‐line therapy for Helicobacter pylori eradication. Cochrane Database of Systematic Reviews, (6).

Zagari, R. M., Rabitti, S., Eusebi, L. H., & Bazzoli, F. (2018). Treatment of Helicobacter pylori infection: A clinical practice update. European journal of clinical investigation48(1), e12857.

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