The Role of Levofloxacin in First-line and "Rescue" Helicobacter pylori Treatment Regimens
Javier P. Gisbert, MD
Gastroenterology Unit, Hospital Universitario de la Princesa and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
Helicobacter pylori (H. pylori) infection is the main cause of gastritis, gastroduodenal ulcers, and gastric cancer. However, after more than 20 years experience with H. pylori treatment, the ideal treatment regimen remains to be found. The most commonly used first-line therapies − including proton pump inhibitors (PPIs) plus clarithromycin and either amoxicillin or metronidazole − may fail in up to 20% of patients. Therefore, clarithromycin-based triple therapies fail to achieve a high enough cure rate, and more effective alternatives should be sought. Levofloxacin is a fluoroquinolone antibacterial agent that exhibits, in vitro, remarkable activity against H. pylori. A synergistic effect of quinolone antimicrobial agents and PPIs on strains of H. pylori has been reported. Furthermore, and very importantly, it has been shown in vitro that levofloxacin retains its activity when H. pylori strains are resistant to clarithromycin and metronidazole. The levofloxacin-amoxicillin-PPI combination represents an alternative to clarithromycin-based therapy, and may be suggested as first-line treatment of H. pylori infection, particularly in areas with high primary resistance to clarithromycin and low resistance to levofloxacin. It has recently been suggested that levofloxacin-based "rescue" therapy also constitutes an encouraging second-line strategy, offering an alternative to quadruple therapy in patients with previous PPI-clarithromycin-amoxicillin failure, with the advantages of improved efficacy, simplicity and safety. Levofloxacin-based "rescue" therapy constitutes an encouraging empirical third-line strategy after multiple previous H. pylori eradication failures with key antibiotics such as amoxicillin, clarithromycin, metronidazole and tetracycline. Finally, the levofloxacin-based regimen can also be administered with good results even after three previous eradication failures with several antibiotics, including rifabutin.