Is sequential therapy superior to standard triple therapy for the treatment of Helicobacter pylori infection?

The challenges posed in the treatment of Helicobacter pylori are increasing: falling rates of eradication and the rising prevalence of antibiotic-resistant H. pylori strains have led to a decline in cure rates. Sequential therapy has been proposed as an alternative to standard triple therapy. The fundamental basis of sequential therapy lies in its superior ability to overcome antibiotic resistance, particularly clarithromycin resistance. The meta-analysis by Jafri et al. shows a potential benefit from using this treatment regimen, but several methodological and practical limitations affect the strength of their conclusions. Greater scrutiny and better designed trials across a much broader range of patients are necessary before guidelines could be supplanted. An expanded role for culture and sensitivity testing might offer the best long-term prospect for the management of H. pylori infection, rather than empirical regimens.