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Reviewer A:
In this prospective, open-label, multicenter study the authors investigated the efficacy of first- (modified
sequential therapy) and second-line therapy (modified levofloxacin-amoxicillin-based triple therapy) in
eradicatingHelicobacter pylori. The results of the study showed that the eradication rate of the modified
sequential therapy was 86% and the intensified second-line therapy was 60%.
COMMENTS
1. The authors should report when this study started and ended, e.g. Over a three year period (Jan. 2007 and
Jan. 2010) …….
R. The study was performed between 1 June 2013 to 31 December 2013. Such an information was provided
in the revised version of the manuscript.
2. In the introduction and discussion sections of the manuscript the authors should comment on the primary
and secondary resistance to antibiotics (Tetra, Clari, Levo) of H. pylori in Italy.
R. Recent data on either clarithromycin or levofloxacin resistance in Italy were added in Discussion.
3. Introduction, second line: “Helicobacter pylori infection is a worldwide disease with a significant morbidity
and mortality”. It is suggested to delete “mortality” since it is not directly but indirectly
related to H. pylori and gastric cancer.
R. A definite mortality is attributable (directly or indirectly) to H. pylori infection, due to gastric cancer, gastric
lymphoma, and peptic ulcer complication. Therefore, the sentence is appropriate.
Reviewer B:
ABSTRACT:
OK
INTRODUCTION:
The authors state that an increased frequency of antibiotic administration from standard twice to thrice daily
is expected to improve antibacterial activity in the stomach. I may also be added that an increased duration
of antibiotic administration is another option to increase the efficacy of H. pylori eradication treatment.
R. We agree with the suggestion. A sentence was added.
The authors point out that the levofloxacin-containing triple therapy has proven to be more effective than
quadruple therapy, and they provide only a single reference (based on a single study); it would be better to
cite the 3 meta-analyses that have demonstrated this, as follows:
Saad RJ, Schoenfeld P, Kim HM, Chey WD. Levofloxacin-based triple therapy versus bismuth-based quadruple
therapy for persistent Helicobacter pylori infection: a meta-analysis. Am J Gastroenterol. 2006
Mar;101(3):488-96.
Gisbert JP, Morena F. Systematic review and meta-analysis: levofloxacin-based rescue regimens after
Helicobacter pylori treatment failure. Aliment Pharmacol Ther. 2006 Jan 1;23(1):35-44.
Li Y, Huang X, Yao L, Shi R, Zhang G. Advantages of Moxifloxacin and Levofloxacin-based triple therapy for
second-line treatments of persistent Helicobacter pylori infection: a meta analysis. Wien Klin Wochenschr.
2010 Jul;122(13-14):413-22.
R. Thanks for the suggestion. We cited a meta-analysis (see new reference 13).
The authors state that the cure rate following triple levofloxacin therapy seems to be decreasing. However,
despite the fact that quinolone resistance is increasing, a reduction in the efficacy has not been demonstrated
by some recent studies, such as: Gisbert JP, Perez-Aisa A, Bermejo F,Castro-Fernandez M, Almela P, Barrio J,
et al. Second-line therapy with levofloxacin after failure of treatment to eradicate helicobacter pylori
infection: time trends in a Spanish Multicenter Study of 1000 patients. J Clin Gastroenterol. 2013
Feb;47(2):130-5. So please, "modulate" this statement.
R. We agree with your observation. However, in the manuscript we refer to Italian data. Indeed, we cited
different Italian studies performed in the last decades showing that the efficacy a second-line therapy with
levofloxacin is clearly decreasing in our country. Likewise, this depends on a high prevalence of primary
levofloxacin resistance in H. pylori isolates in Italy. Such a phenomenon was not observed in Spain. Anyway,
we modulate the sentence and we cited the suggested manuscript.
The rational for the change from standard sequential regimen to a new one with a reduction of the dual
therapy from 5 to 3 days should be better explained.
R. The rationale of reducing the first therapy phase from 5 to 3 days was that the total amoxicillin dose was
substantially unchanged (9 g instead of 10 g; i.e. just 1 tablet less) following amoxicillin administration thrice
daily. This would allow to substantially increase duration of the second therapy phase, from 5 to 7 days,
where 2 antibiotics were administered without increasing the overall duration of therapy (10 days).
The second aim of this study was to appraise the effectiveness as second-line treatment of a modified 10days levofloxacin-based triple therapy by increasing both the PPI dose and antibiotic frequency, aiming to
improve its efficacy. Why not simply prolonging the treatment up to 10-14 days?
R. We agree with your observation. However, at least in theory, the possibilities of improving the success of
a certain therapy are the following: to increase drug doses or therapy duration. In this study, we tested the
first hypothesis, since the a prolonged “7+7” sequential regimen achieved a 91.9% eradication rate (Hsu PI
et al. Helicobacter 2001;16:146–152). We added this information.
METHODS:
A relevant limitation of the present study is that it did not include culture, and therefore the antibiotic
susceptibility of H. pylori infection was unknown. This should be better acknowledged in the Discussion
section.
R. You are right. Nevertheless, as clearly stated in the Methods “This was a prospective, open label, pilot
study”. Generally, the main aim of a pilot study is to assess whether a therapy is effective or not. Only when
a therapy was proven to be effective, data on antibiotic resistance become essential to ascertain whether
the efficacy also persists in the resistant strains. In addition, for the first-line therapy we enrolled only
consecutive patients never previously treated for the infection, whilst in the second-line we used
levofloxacin, i.e. an antibiotic not included in the first-line regimen. Therefore, patients were not selected
based on bacterial resistance.
The duration of the levofloxacin triple therapy should be better justified: why 8 days and not 10-14 days?
R. We have already replied to this observation (see above)
For the second-line therapy, patients who failed sequential therapy, as well as those with persistent infection
following a standard triple therapy observed in same study period were invited to participate. This "mixture"
of studies constitutes another limitation of the present study.
R. As stated, we enrolled patients who failed either the modified sequential therapy or a standard triple
therapy. The antibiotics included in the sequential therapy are not different of them included in triple
therapy. Therefore, we enrolled patients who failed a very similar first-line therapy and for all cases the
levofloxacin-based regimen was the second-line therapy. Consequently, the mixture of these patients would
not appear a limitation of the study.
Was the study approved by the corresponding Ethics Committee?
R. Since we used standard antibiotics currently used for H. pylori eradication according to International
guidelines, and neither experimental drugs nor placebo were used, we did not required Ethics Committee
approval. However, the aim of the study was clearly disclosed to each patients and a written consent to
participate was obtained, as already stated.
Another limitation of the present study is its small sample size (mainly for second-line regimen, where only
15 patients were included). Was the sample size pre-determined (calculated) before the study was initiated?
(both for first-line therapy and also for rescue regimen).
R. As stated, this was a pilot study with a single therapeutic arm for either first- and second-line therapy.
Since no comparison between different therapies was performed, the power study calculation was not
mandatory.
RESULTS:
Detailed adverse events should be provided (in addition to musculoskeletal pain from the patient who
stopped therapy).
R. Many thanks for the suggestion. We added such an information.
DISCUSSION:
The authors state that "Several studies demonstrated that a standard 10-day sequential therapy achieved
high (>90%) cure rates in Italy". Although this is true for some studies, it is also true that, in general, the
efficacy of the sequential regimen in updated meta-analyses has been considerably lower (Gatta L, Vakil N,
Vaira D, Scarpignato C. Global eradication rates for Helicobacter pylori infection: systematic review and metaanalysis of sequential therapy. BMJ. 2013;347:f4587). Please, clarify this in the Discussion.
R. We tested the modified sequential therapy in Italy, where the standard sequential therapy constantly
achieved >90% eradication rate (see reference 23). Therefore, for comparison, we should refer to Italian data.
It is pointed out in the Discussion that "Disappointingly, data of this pilot study showed that the efficacy of
such a modified (3 plus 7) sequential regimen would appear not superior than that of standard (5 plus 5)
sequential regimen". However, to reach this conclusion, a randomized controlled trial would be necessary.
R. A good point. We totally agree with such an observation. Unfortunately, such an “intensified” sequential
regimen failed to achieve an impressively high eradication rate. This would discourage a direct comparison.
The authors state that "Unexpectedly, our data found that such a modified levofloxacin-amoxicillin regimen
achieved unacceptable low eradication rates, despite increased dose of both PPI and antibiotics". However,
I think that this is actually not unexpected, as it is known that the increase in the levefloxacin dose is not
associated with a higher eradication rate (e.g., levofloxacin 1000 mg/day is not better than 500 mg/day):
Cheng HC, Chang WL, Chen WY, Yang HB, Wu JJ, Sheu BS. Levofloxacin-containing triple therapy to eradicate
the persistent H. pyloriafter a failed conventional triple therapy. Helicobacter. 2007
Aug;12(4):359-63.
Di Caro S, Franceschi F, Mariani A, Thompson F, Raimondo D, Masci E, et al. Second-line levofloxacin-based
triple schemes for Helicobacter pylori eradication. Dig Liver Dis. 2009 Jul;41(7):480-5.
Zullo A, De Francesco V, Manes G, Scaccianoce G, Cristofari F, Hassan C. Second-line and rescue therapies for
Helicobacter pylori eradication in clinical practice. J Gastrointestin Liver Dis. 2010 Jun;19(2):131-4
R. Although the observation is acceptable, it should noted that we also increase the total dose of both PPI
and amoxicillin in the second-line regimen. Therefore, we tested a generally “intensified” regimen, rather
than an increase levofloxacin dose. These aspects have been already discussed in the manuscript.
Other studies have previously evaluated the efficacy of levofloacin triple regimen in patients in whom the
sequential regimen had failed, and I suggest briefly mentioning/citing them in the Discussion:
Gisbert JP, Molina-Infante J, Marin AC, Vinagre G, Barrio J, McNicholl AG. Second-line rescue triple therapy
with levofloxacin after failure of non-bismuth quadruple "sequential" or "concomitant" treatment to
eradicate H. pylori infection. Scand J Gastroenterol. 2013 Jun;48(6):652-6
Manfredi M, Bizzarri B, De'angelis GL. Helicobacter pylori Infection: Sequential Therapy Followed by
Levofloxacin-Containing Triple Therapy provides a Good Cumulative Eradication Rate. Helicobacter. 2012
Aug;17(4):246-53.
Perna F, Zullo A, Ricci C, Hassan C, Morini S, Vaira D. Levofloxacin-based triple therapy for Helicobacter pylori
re-treatment: role of bacterial resistance. Dig Liver Dis. 2007 Nov;39(11):1001-5.
Pontone S, Standoli M, Angelini R, Pontone P. Efficacy of H. pylori eradication with a sequential regimen
followed by rescue therapy in clinical practice. Dig Liver Dis. 2010 Aug;42(8):541-3.
Zullo A, De Francesco V, Hassan C. Second-line treatment for Helicobacter pylori eradication after sequential
therapy failure: a pilot study. Therapy. 2006;3:251-4.
R. Many thanks for the suggestion. Our cited the reference 14 already included some of these studies (Perna
et al, Pontone et al, Zullo et al). We cited the other 2 studies you suggested in the revised manuscript.
Finally, the authors' conclusion of that "the intensified second-line regimen most like is unable to overcome
the increased primary resistance to levofloxacin in H. pylori isolated in Italy" is not based on the results of
the present study, as culture was not performed.
R. We agree with your suggestion. We changed the sentence.
Section editor's comments:
The manuscript entitle "First and second line Helicobacter pylori eradication with modified sequential
therapy and modified levofloxacin-amoxicillin-based triple therapy" cannot be accepted in its present form.
However, comments from the reviewers will assist the authors to revise the manuscript accordingly.
Attention should be given to clarify the following issues
1. Why did the authors used these complex treatment regimes. It is the complexity of the regiment(s)
revision(s) that might lead to inconclusive results. E.g. 1st Line therapy: 2 concomitant modifications,
medications given tid for 3+7 days. Similarly for the 2nd Line regimen: medications given tid plus 8
days duration. A simple question is why the authors did not just prolonged the treatments. There is
strong evidence that at least for some of the eradication treatments, prolonged regimen
administration yielded better results. Thus, justification of the tested schemes is required.
R. We agree with your observation. However, at least in theory, the possibilities of improving the
success of a certain therapy are the following: to increase drug doses or therapy duration. In this
study, we tested the first hypothesis, since the a prolonged “7+7” sequential regimen achieved a
91.9% eradication rate (Hsu PI et al. Helicobacter 2001;16:146–152). We added these observations.
2. Ethics committee approval is missing
R. Since we used standard antibiotics currently used for H. pylori eradication according to
International guidelines, and neither experimental drugs nor placebo were used, we did not required
Ethics Committee approval. However, the aim of the study was clearly disclosed to each patients and
a written consent to participate was obtained, as already stated.
3. Presentation of the serious adverse events is missing
R. We cited all the reported side-effects.
4. How patients compliance was assessed. Please give details; given the complexity of the tested
schems, lack of compliance might be responsible for the negative results.
R. As already disclosed “Compliance and incidence of side-effects were evaluated, in addition to selfreporting, by direct interview at the end of therapy”. Indeed, each patient was require to perform a
visit at the end of therapy when these information were achieved and the UBT control was scheduled.