Korean J Helicobacter Up Gastrointest Res.  2021 Mar;21(1):59-71. 10.7704/kjhugr.2020.0053.

Salvage Regimens after Failure of Previous Helicobacter pylori Eradication Therapy: A Systematic Review and Meta-analysis

  • 1Division of Gastroenterology, Department of Internal Medicine and Gastrointestinal Cancer Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
  • 2Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
  • 3Department of Internal Medicine, Seoul National University Hospital Gangnam Center, Seoul, Korea
  • 4Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
  • 5Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
  • 6Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
  • 7Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
  • 8Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
  • 9Center for Gastric Cancer, Kyungpook National University Hospital Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
  • 10Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
  • 11Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
  • 12Center for Gastric Cancer, National Cancer Center, Goyang, Korea
  • 13Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
  • 14Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea


As antibiotic resistance increases and new first-line therapies emerge, salvage therapies for Helicobacter pylori (H. pylori) eradication failures are becoming more common and complicated. This study aimed to systematically review overall salvage regimens after previous failure of H. pylori eradication.
Materials and Methods
A systematic review of randomized clinical trials evaluating salvage therapies after previous H. pylori eradication failure was performed. A meta-analysis was conducted when an adequate number of studies suitable for grouping was found.
Overall, 36 studies with 77 treatment arms were identified, and they were highly heterogeneous regarding previously failed regimens and salvage regimens under comparison. Bismuth quadruple therapy after failure of standard triple therapy showed a pooled intention-to-treat (ITT) eradication rate of 75.5% (95% CI, 71.6~79.1%), and the rates were significantly higher with 14-day therapy than 7-day therapy by 9% (95% CI, 2~15%). Levofloxacin triple therapy after failure of standard triple therapy demonstrated a pooled ITT eradication rate of 73.3% (95% CI, 68.4~77.3%). In direct comparison, the two regimens were not significantly different in eradication rates. No study evaluated salvage regimens after the failure of bismuth or non-bismuth quadruple therapy.
The current studies regarding salvage regimens are highly heterogeneous. Bismuth quadruple therapy and levofloxacin triple therapy may be a reliable option after failure of standard triple therapy, but the regional profile of antibiotic resistance should be considered. Further studies are needed for salvage regimens after failure of non-bismuth or bismuth quadruple therapy.


Drug resistance, Bacterial; Meta-analysis; Salvage therapy; Systematic review
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