Empirical rescue therapy after Helicobacter pylori treatment failure:: a 10-year single-centre study of 500 patients

Background Several 'rescue' therapies have been recommended to eradicate Helicobacter pylori, but they still fail in >20% of the cases, and these patients constitute a therapeutic dilemma. Aim To evaluate the efficacy of different 'rescue' therapies empirically prescribed during 10 years to 500 patients in whom at least one eradication regimen had failed to cure H. pylori infection. Methods Design: Prospective single-centre study. Patients: Consecutive patients in whom at least one eradication regimen had failed. Intervention: Rescue regimens included: (i) quadruple therapy with omeprazole-bismuth-tetracycline-metronidazole; (ii) ranitidine bismuth citrate-tetracycline-metronidazole; (iii) omeprazole-amoxicillin-levofloxacin; and (iv) omeprazole-amoxicillin-rifabutin. Antibiotic susceptibility was unknown (rescue regimens were chosen empirically). Outcome: Eradication was defined as a negative C-13-urea breath test 4-8 weeks after completing therapy. Results Five hundred patients were included (76% functional dyspepsia, 24% peptic ulcer). Compliance rates with first-, second- and third-line regimens were 92%, 92%, and 95%, respectively. Adverse effects were reported by 30%, 37%, and 55% of the patients receiving second-, third-, and fourth-line regimens. Overall, H. pylori cure rates with the second-, third-, and fourth-line rescue regimens were 70%, 74%, and 76%, respectively. Cumulative H. pylori eradication rate with four successive treatments was 99.5%. Conclusion It is possible to construct an overall treatment strategy to maximize H. pylori eradication, on the basis of administration of four consecutive empirical regimens; thus, performing bacterial culture even after a second or third eradication failure may not be necessary.