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Editorial
Helicobacter pylori treatment still remains a challenge for physicians, and no current first-line
therapies are able to cure the infection in all treated patients. Two very large meta-analysis studies
showed that standard 714 days triple therapies
fail to eradicate H. pylori infection in up to
2025% of patients [Fuccio et al. 2007; Zullo et
al. 2007]. In addition, the efficacy of these regimens is even decreasing worldwide. Indeed,
during the last few years, different studies have
found that the success rate following such regimens is disappointingly low, with values less than
4560% in some countries [Gumurdulu et al.
2004; Vakil et al. 2004]. This phenomenon
most likely depends on an increased bacterial
resistance to antibiotics, particularly against clarithromycin the key antibiotic in H. pylori treatment [Megraud 2004]. In detail, clarithromycin
resistance reduces success rate of standard triple
therapies to mean values as low as 1844%.
Consequently, several patients deserve two or
more therapeutic attempts to cure H. pylori infection in clinical practice. Therefore, as well as
first-line regimens, both second-line and rescue
therapies have been advised in the updated international guidelines for H. pylori management
[Caselli et al. 2007; Malfertheiner et al. 2007].
However, to cure the infection following a failed
initial triple therapy is particularly difficult and
costly, due to the need for further therapies and
diagnostic tests. In a recent study, the cumulative
eradication rate was 89.6% by using three consecutive standard therapies in patients treated in clinical practice, being only 70.3%, 69.1% and 70%
following first-, second-, and third-line regimens,
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respectively [Rokkas et al. 2009]. All these observations clearly suggest that more efficacious therapy regimens are required as an initial therapy for
clinical practice, the best first-line treatment being
still regarded as the best rescue therapy [Huang
and Hunt 1999].
In 2000, we conceived a novel therapeutic
approach to cure H. pylori infection, namely a
10-day sequential therapy, which achieved a
very high eradication rate [Zullo et al. 2000].
The sequential therapy is a simple dual therapy
including a proton pump inhibitor (PPI) plus
amoxicillin 1 g (both twice daily) given for the
first 5 days followed by a triple therapy including
a PPI, clarithromycin 500 mg, and tinidazole
(all twice daily) for the remaining 5 days [Zullo
et al. 2007]. To date, the efficacy of such a therapy regimen has been investigated in several trials
overall enrolling more than 2000 patients. Based
on these results, sequential therapy is now recognized as first-line therapy in the current Italian
guidelines [Caselli et al. 2007].
Correspondence to:
Dino Vaira
Department of Internal
Medicine and
Gastroenterology,
University of Bologna,
Bologna, Italy
berardino.vaira@unibo.it
Angelo Zullo
Cesare Hassan
Gastroenterology and
Digestive Endoscopy,
Nuovo Regina Margherita
Hospital, Rome, Italy
Giulia Fiorini
Department of Internal
Medicine and
Gastroenterology,
University of Bologna,
Bologna, Italy
Nimish Vakil
University of Wisconsin
School of Medicine and
Public Health, Madison,
WI, USA
317
Setting
Patients
Cured
ITT (%)
PP (%)
Reference
Italy
Italy
Italy
Italy
Italy
Italy
Italy
Italy
Italy
Italy
Italy
Italy
Italy
Italy
Italy
Romania
Italy
Italy
Italy
Spain
Taiwan
Korea
Panama
Total
Adult
Adult
Adult
Adult
Adult
Adult
Adult
Adult
Adult
Adult
Geriatric
Peadiatric
Adult
Paediatric
Paediatric
Paediatric
Adult
Paediatric
Adult
Adult
Adult
Adult
Adult
52
65
94
522
152
174
162
45
116
40
89
38
72
40
25
45
146
108
90
139
66
77
76
2.433
51
61
90
481
142
166
151
43
110
38
84
36
68
33
23
39
133
92
78
117
59
60
65
2.220
98.1
93.8
95.7
92.1
93.4
95.4
93.2
95.6
94.8
95
94.4
94.7
94.4
82.5
92.0
86.6
91.1
85.2
86.7
84.2
89.4
77.9
85.5
91.2
98.1
96.8
95.7
95.1
96.6
95.4
94.4
97.7
95.6
97.4
96.6
94.7
97.1
82.5
92.0
86.6
93.0
85.2
88.6
90.7
98.3
85.7
85.5
93.7
318
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320
References
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Ferraro, R., Fischbach, L. et al. (2005) Canadian
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Sequential treatment for Helicobacter pylori does not
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