Vonoprazan-containing H. pylori triple therapy contributes to increasing global antimicrobial resistance.
J Gastroenterol Hepatol. 2020 Sep 12;:
Authors: Graham DY, Lu H, Shiotani A
Amoxicillin and proton pump inhibitor dual Helicobacter pylori therapy has proved not to be reliably highly effective primarily because of traditional PPIs inability to maintain a high intragastric pH. Clarithromycin and proton pump inhibitor H, pylori dual therapy failed in part because clarithromycin resistance emerged during therapy causing treatment failures. The combination of amoxicillin, clarithromycin and proton pump inhibitor was subsequently undermined by increasing clarithromycin resistance. Although vonoprazan appeared to restore the effectiveness of triple therapy, the improvement was almost entirely to improved effectiveness of amoxicillin dual therapy component and resulted in the majority (>85% currently in Japan) of those receiving vonoprazan-amoxicillin plus a second antibiotic (e.g., clarithromycin, metronidazole, fluoroquinolone, or rifabutin) receiving no benefit from the second antibiotic. The results in between 2,800 and 5,600 kg of unnecessary clarithromycin per 1 million H. pylori treatment courses per year in Japan. The only contribution of the second antibiotic is to increase global antimicrobial resistance. There are now sufficient data to prove that optimized vonoprazan-amoxicillin dual therapy can reliably achieve cure rates >95%. This manuscript discusses use of the principles of antimicrobial stewardship to develop potassium competitive acid blocker-containing H, pylori therapies that will reliably achieve high H, pylori cure rates with minimal or no use of excess antibiotics. Such therapies are urgently needed so that use of vonoprazan triple therapies can be curtailed while also improving overall H, pylori cure rates.
PMID: 32918832 [PubMed - as supplied by publisher]