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Investigation of Levofloxacin Regimens as Second-line Therapy for Helicobacter pylori

Simona Di Caro, MDa, Lucia Fini, MDb,c, Yayha Daud, PhD.C.d, Antonio Gasbarrini, MDc
a Gastroenterology and Digestive Endoscopy, Royal Berkshire Hospital, Reading, UK
b Department of Gastroenterology, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy
c Internal Medicine Department, Catholic University, Rome, Italy
d Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, TX, USA

Helicobacter pylori (H.pylori) infection chronically affects half of the world's population. Standard first-line triple therapy fails in up to 20% of patients. Clarithromycin and metronidazole resistance are the main cause for decreasing cure rates. The recommended second-line treatment is a quadruple therapy that achieves eradication rates ranging from 65% to 80%. Quadruple therapy is a complex scheme including bismuth salts (no longer available in many countries), characterized by a significant incidence of adverse events. Several regimens have been proposed as alternatives to bismuth-based treatment. The most established schemes include levofloxacin, a fluoroquinolone that has been extensively used worldwide against H.pylori. Many studies have been conducted to identify the optimal levofloxacin-based scheme in first, second and even third-line for H.pylori eradication (drugs combination, dose and duration of therapy). Nevertheless, generalization of results is difficult due to geographical differences in antimicrobial resistance and heterogeneity of the data reported. Recently, the concept of cumulative eradication rate has been introduced to overcome the falling eradication rate. In clinical practice, the treatment strategy for H.pylori cure should focus on the final eradication rate administering the most effective regimen based on antibiotic resistance data, and being prepared to face treatment failure. In the present manuscript the current status of levofloxacin use in second-line therapy for H.pylori eradication has been reviewed, highlighting the differences in various regimens adopted in terms of therapy scheme, tolerability and eradication rate, particularly with respect to standard quadruple therapy.

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