J Korean Med Sci.  2015 Aug;30(8):1001-1009. 10.3346/jkms.2015.30.8.1001.

Treatment of Helicobacter pylori Infection in Korea: A Systematic Review and Meta-analysis

• Lee SW
• Kim HJ
• Kim JG

• KMID: 2164492
• DOI: http://doi.org/10.3346/jkms.2015.30.8.1001

Abstract

The efficacy of seven-day clarithromycin-based standard triple therapy (STT) for Helicobacter pylori has decreased in Korea over the past decade. The aim of this meta-analysis was to clarify the efficacy of first-line and second-line therapies in Korea. This systematic review will provide an overview of H. pylori eradication and present new therapeutic strategies used in Korea. An extensive search of the literature concerning STT, sequential therapy (SET), concomitant therapy (CT), bismuth-containing quadruple therapy (BCQT) and various other therapies used in Korea was performed. All selected studies were randomized controlled trials (RCTs). Eighteen RCTs were eligible for systematic review. The alternative regimens comparing seven-day STT as a first-line therapy include SET, CT, levofloxacin-based therapy (LBT), BCQT, and STT with prolonged duration. The results of the meta-analysis suggest that SET is superior to seven-day STT. The overall eradication rate by intention to treat (ITT) analysis was 69.8% for STT and 79.7% for SET. The overall eradication rate by per-protocol (PP) analysis was 77.0% for STT and 85.0% for SET. The odds ratios for the ITT and PP eradication rate were 0.57 (95% confidence interval [CI], 0.43 to 0.74) and 0.52 (95% CI, 0.35 to 0.76), respectively. In the subgroup analysis, however, there were no significant differences between SET and STT with prolonged durations. Alternative regimens to seven-day BCQT as second-line therapy include LBT, moxifloxacin-based therapy and 14-day BCQT. The eradication rates of these alternative regimens were not superior to that of the conventional treatment. SET is superior to seven-day STT but not to STT with prolonged duration.

Keyword

Helicobacter pylori; Treatment; Disease Eradication; Review; Systematic

MeSH Terms

Anti-Bacterial Agents/*administration & dosage/classification
Evidence-Based Medicine
Female
Helicobacter Infections/*drug therapy/*epidemiology/microbiology
Helicobacter pylori/*drug effects
Humans
Male
Practice Patterns, Physicians'/*statistics & numerical data
Prevalence
Republic of Korea/epidemiology
Risk Assessment
Treatment Outcome
Anti-Bacterial Agents

Figure

• 

  Fig. 1 Flow diagram of selected trials. The initial search yielded 1,304 citations. Ultimately, 18 articles were eligible for systematic review.

• 

  Fig. 2 The risk of bias summary. Risk of bias according to the Cochrane Collaboration was used to assess risk of bias in the included studies. Many items were judged as unclear (reported in yellow) because the study did not report enough information for a proper evaluation. The figures show that the overall risk of bias is low (reported in green), but performance bias is high (reported in red).

• 

  Fig. 3 Forest plot of the nine studies comparing STT with alternative regimens of first-line therapy including SET, CT, BCQT and LBT according to ITT analysis (A) and PP analysis (B). The effect of STT was inferior to other therapies with regard to eradication rate. STT, standard triple therapy; SET, sequential therapy; CT, concomitant therapy; BCQT, bismuth-containing quadruple therapy; LBT, levofloxacin-based therapy; CI, confidence interval. The studies concerning SET are as follows: 1) H.G. Park et al., 2012; 2) H.S Choi et al., 2012; 3) H.S Oh et al., 2011; 4) J.W. Chung et al., 2012; 5) W.H. Choi et al., 2008; 6) Y.S. Kim et al., 2011; The study concerning on CT is 7) S.Y. Kim et al., 2013. The study on bismuth-containing quadruple therapy is 8) J.H. Jang et al.,2005. The study concerning levofloxacin-based therapy is 9) K.H. Choi et al., 2011.

• 

  Fig. 4 Forest plot of the six studies comparing STT with SET as first-line therapy and subgroup analysis by duration according to ITT analysis (A) and PP analysis (B). SET was superior to STT with regard to eradication rate. In the subgroup analysis, however, there was no significant difference between SET and STT with regard to prolonged treatment duration. STT, standard triple therapy; SET, sequential therapy; CI, confidence interval. The studies concerning seven-day STT are as follows: 1) H. G. Park et al., 2012; 2) H. S. Choi et al., 2012; 3) H. S. Oh et al., 2011; 4) W. H. Choi et al., 2008. The studies concerning 10-day STT are as follows: 1) H. S. Choi et al., 2012; 2) J. W. Chung et al., 2012. The studies concerning 14-day STT are as follows: 1) H. S. Choi et al., 2012; 2) Y. S. Kim et al., 2011.

• 

  Fig. 5 Forest plot of the two studies on treatment duration of STT according to PP analysis. There was no significant difference between the effect of seven-day and 14-day STT on eradication rate by PP analysis. STT, standard triple therapy; CI, confidence interval.

• 

  Fig. 6 Forest plot of the three studies comparing BCQT with alternative regimens of second-line therapy including LBT and MBT on ITT analysis (A) and PP analysis (B). There were no significant differences between BCQT and other therapies. BCQT, bismuth-containing quadruple therapy; LBT, levofloxacin-based therapy; MBT. moxifloxacin-based therapy; CI, confidence interval. The study concerning LBT is 1) H. S. Jung et al., 2012. The studies concerning MBT are as follows: 1) J. H. Cheon et al., 2006; 2) J. M. Kang et al., 2007.

• 

  Fig. 7 Forest plot of the three studies on treatment duration of BCQT on ITT analysis (A) and PP analysis (B). There was no significant difference between the effect of seven-day and 14-day BCQT on eradication rate by ITT analysis. However, there was borderline statistical significance between the effect of seven-day and 14-day BCQT on eradication rate by PP analysis. BCQT, bismuth-containing quadruple therapy; CI, confidence interval.

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