Comparing Nonbismuth Quadruple Regimens for Helicobacter Pylori Eradication

David J. Bjorkman, MD, MSPH (HSA), SM (Epid.)

A concomitant regimen and a partly sequential regimen of the same drugs had similarly high efficacy in areas with high antibiotic resistance.

Eradication rates of Helicobacter pylori with standard therapy are decreasing as antibiotic resistance increases in many countries. Bismuth-based therapies have shown some promise (NEJM JW Gastroenterol Jul 8 2013), but nonbismuth therapies remain common. Now, researchers have compared the efficacy of two nonbismuth, quadruple regimens — one concomitant and one partly sequential — in areas of Spain and Italy with similarly high rates of clarithromycin resistance (approximately 20%).

In a multicenter, noninferiority trial, investigators randomized 343 treatment-naive patients with H. pylori infection to receive 40 mg of omeprazole, 1 g of amoxicillin, 500 mg of clarithromycin, and 500 mg of nitroimidazole twice daily for 14 days (concomitant therapy), or the same regimen but with clarithromycin and nitroimidazole limited to the last 7 days (hybrid therapy). In 77 patients evaluated, antibiotic resistance was high (23.5% to clarithromycin, 33.0% to metronidazole, and 8.8% to both).

Eradication rates based on intention-to-treat were 90% for patients who received hybrid therapy and 91.7% for patients who received concomitant therapy. The authors concluded that optimized quadruple therapy using either approach is effective for H. pylori eradication in areas of high antibiotic resistance.

CITATION(S):

Molina-Infante J et al. Optimized nonbismuth quadruple therapies cure most patients with Helicobacter pylori infection in populations with high rates of antibiotic resistance. Gastroenterology 2013 Jul; 145:121.