[Rescue therapy after Helicobacter pylori eradication failure]

Despite the use of currently-recommended therapies, at least 20% of patients remain infected after a first attempt at Helicobacter pylori eradication. Therefore, when designing a therapeutic strategy, rather than focus exclusively on the result of the first eradication therapy, from the outset physicians should plan the sequence of consecutively administered combinations with the highest possibility of achieving a 100% success rate. The choice of rescue therapy depends on the drugs used in the first eradication attempt, since repeating the same antibiotic is not recommended. Systematic bacterial culture after a first H. pylori eradication failure does not seem to be required in clinical practice and this technique can be reserved for patients with a second failed attempt. There are several possibilities for empirical rescue therapy (without knowing the bacterial sensitivity). After failure of the combination of a proton pump inhibitor (PPI), amoxicillin and clarithromycin -the most widely used combination in Spain-, quadruple therapy (PPI-bismuth-tetracycline-metronidazole) has been the most widely used treatment. More recently, levofloxacin (together with amoxicillin and a PPI) is as effective as quadruple therapy, or more so, and has the advantage of being simpler and better tolerated. In addition, rescue therapy with levofloxacin is a promising third-line alternative after failure of two eradication therapies containing key antibiotics such as amoxicillin, clarithromycin, metronidazole and tetracycline. Finally, rifabutin-based therapies have achieved promising results and are even effective in patients with multiple failures or multiple antibiotic resistance.