What regimens eradicate Heliobacter pylori?

Evidence summary

The ideal H pylori eradication regimen should reach an intention-to-treat cure rate of 80% (Table).¹ Effective regimens are:

Fourteen-day triple therapy of PPI + clarithromycin + metronidazole or amoxicillin. A meta-analysis of 13 studies found the eradication rate for 14-day therapy was 81% (95% confidence interval [CI], 77%–85%), compared with 72% (95% CI, 68%–76%) for 7-day therapy. The eradication rate for 10-day therapy (83%; 95% CI, 75%–89%), however, was not significantly better than that for 7-day therapy (80%; 95% CI, 71%–86%).² Side effects were more frequent in the longer therapies, but did not lead to discontinuation of therapy.

Seven-day triple therapy of PPI + clarithromycin + metronidazole or amoxicillin. A high-quality systematic review of 82 studies using 7-day triple therapy found clarithromycin 500 twice daily yielded a higher eradication rate than clarithromycin 250 mg twice daily when combined with a PPI and amoxicillin (87% vs 81%; P<.0001). When clarithromycin was combined with a PPI and metronidazole, the higher dose of clarithromycin did not yield significantly higher eradication rates (88% vs 89%, P=.259).³

Seven-day triple therapy of ranitidine bismuth citrate + clarithromycin + metronidazole or amoxicillin. For these therapies, a high-quality systematic review of 8 studies reported eradication rates of 81% (95% CI, 77%–84%) with amoxicillin and 88% (95% CI, 85%–90%) with metronidazole.^4,5 Side effects were not reported in a uniform manner for the 7-day therapies, but were noted to be mild and did not lead to significant discontinuation of therapy. Pooled dropout rates were similar among all regimens.⁴

Three-day quadruple therapy of PPI + bismuth + clarithromycin + metronidazole or PPI+ clarithromycin + amoxicillin + metronidazole. An otherwise high-quality but unblinded randomized clinical trial of 234 patients demonstrated that 2 days of pretreatment with lansoprazole followed by 3 days of lansoprazole with clarithromycin, amoxicillin, and metronidazole yielded eradication rates comparable with 5-day treatment (81% vs. 89%; P<.05).⁶

Another randomized clinical trial of 118 patients, blinded to investigators but not patients, showed that quadruple 3-day therapy with lansoprazole + bismuth + clarithromycin + metronidazole was as effective as 7 days of lansoprazole + clarithromycin + metronidazole (87% vs 86%; P=.94), and had significantly shorter duration of side effects (2.6 vs 6.2 days; P<.001). Eradication rates were similar in isolates that were resistant or sensitive to either metronidazole or clarithromycin.⁷

The problems of emerging clarithromycin and metronidazole resistance have not been

extensively studied. In 1 review, metronida-zole-containing regimens eradicated metronidazole-sensitive strains more effectively than metronidazole-resistant strains (weighted difference, 15%; 95% CI, 8%–20%).⁴ When an infection is resistant to metronidazole, amoxicillin should be used instead.⁴ In areas of high clarithromycin and metronidazole resistance, a quadruple regimen might be more effective.⁷

TABLE
Effective therapies for Heliobacter pylorieradication