Levofloxacin or Clarithromycin-based quadruple regimens: what is the best alternative as first-line treatment for Helicobacter pylori eradication in a country with high resistance rates for both antibiotics?

BACKGROUND: Helicobacter pylori eradication rates in Portugal are declining, due to increased resistance of this bacterium to antimicrobial agents, especially Clarithromycin. Quadruple Levofloxacin-containing regimens could be an option for first-line treatment, but its efficacy should be evaluated as fluoroquinolone resistance is rapidly increasing. Our aim was to compare the efficacy of Clarithromycin and Levofloxacin-based sequential quadruple therapies as first-line treatment options and determine factors associated with treatment failure. METHODS: A total of 200 Helicobacter pylori infected patients were retrospectively included (female 57.5%; average age: 53.2 ± 15.7) and received either 10-day sequential therapy (Proton-Pump Inhibitor + Amoxicillin 1 g bid for 5 days and Proton-Pump Inhibitor + Clarithromycin 500 mg + Metronidazole/Tinidazole 500 mg bid/tid in the following 5 days; group A) or a 10-day modified sequential therapy with Levofloxacin 500 mg id instead of Clarithromycin (group B). Eradication was confirmed with urea breath test. Variables that could influence success rate were analyzed. RESULTS: There were no differences between groups in terms of gender, age, smoking habits and indications for treatment. The eradication rate obtained with Clarithromycin-based sequential treatment was significantly higher than with Levofloxacin-based therapy (90%, CI95%: 84-96% vs. 79%, CI95%: 71-87%, p = 0.001). Using full-dose proton-pump inhibitor and high-dose Metronidazole in group A, and full-dose proton-pump inhibitor and prescription from a Gastroenterologist in group B were associated with eradication success. CONCLUSIONS: Ten-day Levofloxacin-based sequential treatment achieved inadequate efficacy rate (<80%) and should not be adopted as first-line therapy. Standard sequential therapy showed significantly better results in this naïve population. Using full-dose proton-pump inhibitor and higher doses of Metronidazole is essential to achieve such results.

In-hospital mortality in spontaneous bacterial peritonitis: a new predictive model.

INTRODUCTION AND OBJECTIVE: Spontaneous bacterial peritonitis (SBP) is a severe complication in cirrhotics with ascites. Early identification of high-risk patients is crucial for prognostic improvement. Model for end-stage liver disease (MELD) relies on a few objective variables and predicts short-term survival. We aimed to determine the predictive value of MELD score, at admission, in the short-term mortality of SBP patients. METHODS: We conducted a retrospective study of 73 SBP episodes admitted in our department between January 2002 and April 2006. Diagnosis (neutrophil count in ascitic fluid >or=250/mm3) was established within 24 h and cefotaxime was immediately started. Data collected included age, sex, etiology of liver disease, severity of ascites and hepatic encephalopathy, serum creatinine, total bilirubin and albumin, prothrombin time with international normalized ratio, and ascitic fluid analysis. STATISTICS: Student's t-test, chi2 test, univariate analysis, logistic regression model, and receiver operating characteristic curves. RESULTS: In-hospital mortality rate was 37%. In multivariate analysis, MELD score (P<0.001), and advanced age (P<0.05) were independent predictors of mortality. Receiver operating characteristic curve for MELD score revealed an excellent discriminatory ability to predict death, with an area under curve of 0.84. Age increased the predictive ability of MELD score, represented by an increment of area under curve to 0.88. CONCLUSION: MELD score and older age were independent predictors of mortality. Age increased the discriminatory ability of MELD score to predict death. This new model may be useful for stratifying patients in future therapeutic trials, deserving further validation.

Value of reagent strips in the rapid diagnosis of spontaneous bacterial peritonitis.

BACKGROUND/AIMS: Spontaneous bacterial peritonitis is a severe complication in cirrhotic patients with ascites. Early antibiotics are essential to improve the prognosis. An ascites neutrophil count >250/mm3 is an indication for antibiotic therapy. However this procedure requires intensive labor and is not available in all hospitals on emergency setting. The aim of this study was to assess the utility of Human-Test Combina strips for the rapid diagnosis of spontaneous bacterial peritonitis. The interobserver variability in the result reading was also evaluated. METHODOLOGY: A prospective study of 109 consecutive ascitic fluid samples colected from 55 patients was carried out. The results of the reagent strips were compared with the neutrophil count by conventional optical microscopy. Interobserver agreement was tested in 37 cases. RESULTS: The prevalence of infection was 8.3%. Reagent strips had sensitivity, specificity, positive and negative predictive values of 78%, 88%, 37% and 98% for a cut-off level > or =2 and 67%, 98%, 75% and 97% for > or =3, respectively. Concordance between investigators was 100%. CONCLUSIONS: Reagent strips are a rapid, simple and easily available method for the diagnosis of spontaneous bacterial peritonitis. A positive result should be an indication to start antibiotics and a negative result can be useful to exclude the possibility of infection.