ITT analysis showed a superior eradication rate of 77.3% compared to 64.5% for amoxicillin, clarithromycin, bismuth, and omeprazole [33]. Levofloxacin therapy is another reasonable option for second-line therapy. A 10 -day trial in Spain involving 300 patients showed an 81% per-protocol and 77% in the ITT analysis eradication rate for levofloxacin-based second-line therapy [34]. Penicillin allergic patients who require second-line therapy are a particular challenge to clinicians. It appears that

levofloxacin may also be worthwhile here with a recent study concluding that a levofloxacin-containing regimen (together with omeprazole and clarithromycin) represents an encouraging second line alternative in the presence of penicillin allergy [35]. The concerns regarding

quinolone resistance outlined previously, however, may limit the utility of this antibiotic for H. pylori eradication. selleck kinase inhibitor In addition, there are safety concerns regarding fluoroquinolones and levofloxacin in particular, with respect to tendonitis. Tendonitis was reported in 704 of 46,000 patients receiving levofloxacin, which may not always resolve upon discontinuation of the drug, and it is not subject to EMEA and FDA box warnings [36,37]. Rescue regimens for H. pylori infection are largely empirical, and many have been proposed to answer this challenging clinical conundrum [38]. Furazolidone is a synthetic nitrofuran derivative, which has an antibacterial and antiprotozoal efficacy against many gram-negative enteric organisms. It is difficult to source commercially in Europe. It is a useful Selleckchem PD332991 option for treatment failures [39,40].

A study of 10 patients, in whom first-line, second-line and rifabutin-based therapy had failed revealed 60% eradication when it was used along with amoxicillin and proton-pump inhibitor [41]. When furazolidone is used with levofloxacin, efficacy is better with 83% eradication by ITT; however, in fourth-line therapy this is reduced to 57% [42]. When these data were incorporated into selleck inhibitor a systematic review of furazolidone-based treatments for third and subsequent line eradication therapy, they were shown to be effective overall 65% of the time [43]. Rifabutin is an antituberculous agent, which can be administered as proton-pump inhibitor, rifabutin (150 mg), amoxicillin (1 g), all twice daily for 10–14 days for H.  pylori eradication purposes [44]. As an example, one study on rifabutin used for treatment failures achieved 79% eradication rate for third-line therapy [45]. Another study limited to patients who did not achieve eradication with standard first-line or bismuth-based second-line therapy revealed 79% eradication rates based on ITT analysis [46]. However, rifabutin is limited as a treatment option by a number of factors. Stocks are low in Europe. Also, rifabutin is a useful tool in the treatment of the increasingly problematic multidrug resistant tuberculosis infection.