How to treat Helicobacter pylori: First-line, second-line, and future therapies

Numerous trials have been performed during the 1990s to define the optimal therapy for H. pylori infections. The proposed PPI-based and RBC-based triple therapies lead to satisfactory results. Their first drawback is their cost, and for this reason, many infected people who need treatment worldwide cannot benefit from these regimens. Combinations including bismuth salts and furazolidone, although less convenient and inducing more side effects, can achieve the same goal, however. Failures of first-line therapies essentially are due to antimicrobial resistance, which increases with the selection pressure resulting from the use of these drugs. Second-line treatments using antimicrobial agents for which H. pylori resistance is low or nonexistent are being tested to find alternatives to the quadruple therapy. Ciprofloxacin or tetracycline administered with amoxicillin and a PPI has not achieved this goal, in contrast to rifabutin. Combinations including metronidazole with amoxicillin and PPI or with tetracycline and RBC also are potential solutions. There is a need for new drugs, which should be highly effective, nonselective of resistant strains, and without side effects, to improve current regimens. These drugs may be the results of postgenomic studies.