Empiric treatments for Helicobacter pylori compared

Concomitant therapy and bismuth quadruple therapy appear to have the highest eradication rates for Helicobacter pylori infection in U.S. community settings, a recent study found.

Researchers performed a retrospective cohort study using data from Kaiser Permanente Northern California to compare the effectiveness of initial and salvage H. pylori treatment regimens in 2000 to 2022. Effectiveness was assessed overall and separately for 10-day and 14-day regimens, while changes in effectiveness over time were evaluated in five intervals (2000-2003, 2004-2007, 2008-2012, 2013-2017, and 2018-2022). The results were published July 14 by Clinical Gastroenterology & Hepatology.

The study included 26,669 H. pylori-infected patients receiving initial treatment (5,400 on 10-day regimens and 21,269 on 14-day regimens) and 5,389 receiving salvage treatment (1,225 on 10-day regimens and 4,164 on 14-day regimens). Eradication rates were highest with concomitant therapy, defined as 14-day regimens of proton-pump inhibitor (PPI)/amoxicillin/clarithromycin/metronidazole (PACM-14), and bismuth quadruple therapy, defined as PPI/bismuth/metronidazole/tetracycline (PBMT-14) (89.8% and 89.3%, respectively), and did not decline substantially over time.

Significantly lower eradication rates were seen for all regimens as salvage treatment, with the highest at 69.3% for PBMT-14. Eradication rates were significantly lower for regimens containing clarithromycin or metronidazole if patients had previously taken macrolides or metronidazole (adjusted odds ratios [aORs], 0.68 [95% CI, 0.60 to 0.77] for PACM-14 and 0.61 [95% CI, 0.50 to 0.75] for PBMT-14). Repeated use of the same previously prescribed regimens was also associated with significantly lower eradication rates (aORs, 0.46 [95% CI, 0.35 to 0.61] for PACM-14 and 0.51 [95% CI, 0.39 to 0.67] for PBMT-14).

Limitations include that the study involved only patients who tested positive for H. pylori by nonserologic methods and that effectiveness could be assessed only in patients who received confirmatory testing after treatment, the authors noted. They concluded that in this large study population, concomitant and bismuth quadruple therapies had the highest H. pylori eradication rates in treatment-naive patients without a meaningful decrease in efficacy over time and bismuth quadruple therapy was the most successful salvage regimen.

“Our findings also underscored the importance of reviewing history of macrolide or nitroimidazole antibiotics use when prescribing H. pylori treatment regimens and avoiding any regimens that were prescribed previously,” the authors wrote. “Taken together, our findings provide important new data on comparative effectiveness of commonly used H. pylori treatment regimens in community-based U.S. populations and will inform clinical practice by optimizing selection of treatment regimens in order to maximize H. pylori eradication success.”