Another study from the Middle East looked

at whether combining clarithromycin and levofloxacin in the same regimen could be effective and found a 90% eradication rate for a combined clarithromycin–levofloxacin–esomeprazole regimen compared with 85% for levofloxacin–amoxycillin–esomeprazole selleck and 79% for clarithromycin–amoxycillin–esomeprazole with no difference in the incidence or severity of adverse events [11]. The question remains, though, as to whether levofloxacin’s best place is as first- or second-line therapy. A crossover study published last year indicates that a clarithromycin–amoxycillin–lansoprazole regimen performs better than a levofloxacin–amoxycillin–lansoprazole regimen as first-line therapy (84 vs 74%), but this is reversed in second-line therapy (77 vs 60%) [12]. The eradication rate was significantly lower in the presence of levofloxacin resistance in the levofloxacin–amoxycillin–lansoprazole group (50 vs 84%). Resistance

to levofloxacin is a growing problem with a report of unpublished data suggesting LEE011 concentration that levofloxacin resistance in Spain may have increased from 6% to more than 25% over the last 5 years [13]. Another role of levofloxacin may be in the treatment of patients with penicillin allergies. In a study of a levofloxacin-based regimen used in penicillin-allergic patients after omeprazole–clarithromycin–metronidazole had been unsuccessful, MCE公司 eradication rates of 73% were noted [14]. Few data are available on the role of other fluoroquinolones in the management of H. pylori infection. However, a meta-analysis of moxifloxacin-based second-line

regimens showed it to be both better tolerated and more efficacious (75 vs 61%) than a bismuth-containing quadruple therapy [15]. The role of bismuth as both a first- and second-line eradication agent has also been examined this year. A meta-analysis on the topic illustrated that bismuth-based quadruple therapy and standard triple therapy had similar rates of eradication and side effect profiles [16]. Quadruple therapy is associated with high cure rates, yet its complex administration protocol hampers its acceptability for general use. A recent study has assessed the efficacy and safety of a novel, single-capsule bismuth-containing quadruple therapy. This multicenter study of a 10-day bismuth-based quadruple therapy (bismuth–metronidazole–tetracycline–omeprazole) as first-line therapy showed an eradication rate of 80% in the quadruple therapy group versus 55% for the standard 7-day triple-therapy group [17]. However, recent commentaries have suggested that the methodology used in this study was quite conservative. Indeed, those having follow-up urea breath testing outside of the time frame were considered as having persistent infection and if these cases were not included the rate of cure went up to 93% via intention-to-treat analysis [18].