Eradication of Helicobacter pylori Infection with Non-Bismuth Quadruple Concomitant Therapy
Pp. 1-34 (34)
Javier P. Gisbert and Adrian G. McNicholl
Background: The main recommended regimens to eradicate Helicobacter
pylori infection fail in ≥20% of the cases. Several substitutes for triple therapies have
been proposed, and non-bismuth quadruple therapy is one of the most widely used.
Aim: To systematically review the efficacy of non-bismuth quadruple regimen (proton
pump inhibitor, clarithromycin, amoxicillin and a nitroimidazole) in the eradication of
H. pylori infection.
Methods: Bibliographical searches were performed in MEDLINE/EMBASE and
relevant congresses. We pooled studies evaluating the concomitant regimen, and of the
randomized controlled trials comparing concomitant vs. standard triple therapy, and
concomitant vs. sequential therapy.
Results: Fifty-five studies were included (6,906 patients). The meta-analysis showed
that concomitant regimen offers an overall eradication rate of 87%. A sub-analysis of
studies comparing one-to-one concomitant and triple therapies showed an odds ratio of
2.14 (95% CI=1.51-3.04) towards higher efficacy with concomitant regimen. This
figure increased up to 2.41 (95% CI=1.80-3.24; 85% vs. 72%) when comparing arms
lasting the same number of days. We also sub-analyzed the comparative efficacy
between non-bismuth quadruple concomitant and sequential treatments, and
concomitant achieved an odds ratio of 1.49 (95% CI=1.21-1.85) towards higher
eradication results than sequential regimen.
Conclusions: Non-bismuth quadruple (concomitant) therapy achieves high efficacy in
H. pylori eradication, superior to standard triple and sequential therapy. Concomitant
may be more appropriate than sequential therapy for patients with clarithromycin
and/or metronidazole resistance. Higher acid suppression and/or longer duration are
optimizations that can increase even more its efficacy.
amoxicillin, clarithromycin, concomitant therapy, Helicobacter
pylori, metronidazole, non-bismuth quadruple, proton pump inhibitor, resistance,
sequential therapy, treatment.
Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autonoma de Madrid (UAM), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.