Manfredi et al. [1] had chosen a 10-day levofloxacin containing triple therapy that achieved a cure rate below 80%. Meta-analyses have shown that 7-day fluoroquinolone triple therapy typically provides unacceptably low treatment success, 10-day regimens yield borderline acceptable results (e.g. 84–89% treatment success), and neither provides reliable >90 or 95% cure rates [6,7]. Recently, a trial of 14-day fluoroquinolone triple therapy provided 95% success suggesting that it is possible to achieve high level success with this combination [8]. However, resistance to

fluoroquinolones is rapidly increasing worldwide, and the presence of resistance is a likely explanation for the relatively low cure rates experienced by Manfredi et al. Increasingly common resistance suggests that fluoroquinolone-containing regimens should only be used in areas where resistance RGFP966 in vitro is known to still be low or pretreatment susceptibility testing has been performed

[9]. Furthermore, fluoroquinolones are expensive and have “black box” warnings. Thus, we can not concur with the Manfredi et al. [1] suggestion that a 10-day fluoroquinolone triple therapy would be an excellent choice to “eradicate Helicobacter pylori infection in only two rounds”. We recommend that the same considerations for choosing first-line empiric therapy be employed for choosing second-line

therapy (i.e. that drugs used in previous H. pylori treatment schedules for which resistance has likely MK-1775 mw developed or those with predictable high primary resistance rates should be avoided). The second line should be the combination that is known to work best locally (Fig. 2) [5,9]. Where available, bismuth-containing quadruple therapy is often an excellent choice provided that one prescribe appropriate doses and for at least 10 or preferably 14 days. 4��8C Seven-day bismuth-containing quadruple therapy is insufficient to overcome metronidazole resistance [10], which likely explains why a recent meta-analysis reported that 7-day bismuth quadruple was inferior to 10-day levofloxacin triple therapy as a second-line therapy [6]. In conclusion, the best locally available therapy should be used for both first-line and for second-line therapy. After the failure of a clarithromycin-containing four-drug first-line therapy (e.g. sequential or concomitant), current best alternatives are either a bismuth quadruple therapy where available or a fluoroquinolone-containing triple therapy. Our suggestion, however, is to give both for 14 days and avoid levofloxacin in areas where H. pylori fluoroquinolone resistance is known to have increased enough to jeopardize therapy results. The final goal should be achieving at least 90% treatment success also with second-line therapy. Dr.