Understanding treatment guidelines with bismuth and non-bismuth quadruple Helicobacter pylori eradication therapies

ABSTRACT

Introduction: Recent Helicobacter pylori treatment guidelines recommend the 4-drug combinations bismuth quadruple therapy and concomitant therapy.

Areas covered: We review antimicrobial therapy for H. pylori in the context of antimicrobial therapy in general and specifically in relation to good antimicrobial stewardship (defined as optimal selection, dose, and duration of an antimicrobial that results in the best clinical outcome for the treatment of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance).

Expert commentary: The lack of regional and local H. pylori susceptibility data prevents implementation of susceptibility-based antimicrobial therapy and forces compromises. Bismuth quadruple therapy employing at least 1,500 mg of metronidazole for 14 days is effective despite metronidazole resistance. The main drawback is side effects causing reduced adherence. Versions where amoxicillin replaces metronidazole or tetracycline also appear effective. It is likely that bismuth quadruple therapy can be simplified by giving bismuth and possibly tetracycline b.i.d., possibly with fewer side effects. Concomitant therapy (a proton pump inhibitor, metronidazole, clarithromycin, amoxicillin) is ineffective with dual clarithromycin-metronidazole resistance and all patients receive at least one unnecessary antibiotic thus promoting antimicrobial resistance worldwide. Concomitant therapy should be abandoned when susceptibility testing becomes widespread or an alternate becomes available.

KEYWORDS:

• Amoxicillin
• antibiotic misuse
• antimicrobial stewardship
• bismuth
• clarithromycin
• Helicobacter pylori
• metronidazole
• proton pump inhibitor
• resistance
• susceptibility
• tetracycline
• vonoprazan

Declaration of interest

D Graham is a consultant for RedHill Biopharma regarding novel H. pylori therapies. He has also received research support for culture of Helicobacter pylori and is the PI of an international study of the use of antimycobacterial therapy for Crohn’s disease. He is also a consultant for BioGaia in relation to probiotic therapy for H. pylori infection and for Takeda in relation to H. pylori therapies. Dr. Dore received an unconditional grant from BioGaia in relation to probiotic therapy for H. pylori infection. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

A reviewer on this manuscript has disclosed past authorship with an author on the paper; this reviewer met the criteria laid out in the editorial departments peer review protocol.

Additional information

Funding

The manuscript was funded by the U.S. Department of Health and Human Services, National Institutes of Health and the National Institute of Diabetes and Digestive and Kidney Diseases, [DK56338].