H Pylori : Alternatives to Clarithromycin

• No sufficient evidence of comparison among the alternatives

Metronidazole

• Triple therapy for H  pylori infection remains an option for first-line therapy in areas of low clarithromycin resistance (<15%) and consists of the following:
• Proton pump inhibitor (PPI) (eg, omeprazole 20 mg BID, lansoprazole 30 mg BID, esomeprazole 40 mg QD, pantoprazole 40 mg QD, rabeprazole 20 mg BID) plus Clarithromycin 500 mg BID  (first-line) or metronidazole 500 mg BID(when clarithromycin resistance is increasing) plus Amoxicillin 1000 mg BIDor metronidazole  (if not already selected)

Tetracycline

• Sequential therapy is superior to standard triple therapy, according to two systematic reviews, and consists of the following:
• PPI plus amoxicillin for 5-7 days (eg, pantoprazole 40 mg BID and amoxicillin 1 g BID for 7 days ), then
• tetracycline-based regimens (eg, pantoprazole 40 mg BID, tetracycline 500 mg QID, and metronidazole 500 mg BID) are superior to 14-day triple therapy, based on a meta-analysis of 21 trials

Levofloxacin

• This is an alternative first-line regimen and consists of a PPI plus amoxicillin 1 g BID plus levofloxacin 500 mg QD
• Sequential therapy, an alternative first-line regimen, is as follows (eradication rates of up to 86.5%):
• PPI (esomeprazole 20 mg or 40 mg BID) plus amoxicillin (1 g BID) for 5-7 days, then
• PPI (esomeprazole 20 mg or 40 mg BID) plus levofloxacin (250 mg or 500 mg BID) plus another antibiotic (eg, tinidazole 500 mg BID) for 5-7 days
• Levofloxacin-based sequential therapy is superior to clarithromycin- and tetracycline-based therapies and consists of the following (eradication rates of up to 92.2%, as long as the H pylori was susceptible to levofloxacin):
• PPI (esomeprazole 40 mg BID) + amoxicillin (1 g BID) for 7 days, then
• PPI (esomeprazole 40 mg BID) + metronidazole (500 mg BID) + levofloxacin (250 mg or 500 mg BID, with the former surprisingly achieving higher cure rates) for another 7 days

Azithromycin

• regimen containing 20 mg omeprazole, 500 mg amoxicillin, and 250 mg clarithromycin twice a day for 14 days
• high rate of H. pylori eradication (81%) in both groups, with no statistical differences between the two regimens (clarithromycin vs azithromycin)
• In summary, the conclusion of this systematic review and meta-analysis is that, for first-time treatment, azithromycin-containing triple therapy has equal efficacy to that of standard triple eradication therapy.
• A combination of azithromycin, amoxicillin and a PPI constitutes an encouraging empirical first-line strategy. Furthermore, azithromycin-containing triple therapy showed a lower occurrence of drug-related side effects

References:

1. http://emedicine.medscape.com/article
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797669/
3. http://numonthly.com/2794.fulltext