Susceptibility-Guided Therapy vs. Bismuth-Containing Quadruple Therapy as the First-Line Treatment for Helicobacter pylori Infection: A Systematic Review and Meta-Analysis

Abstract

BackgroundThe increased antibiotic resistance of Helicobacter pylori (H. pylori) has led to the decreased efficacy of H. pylori regimens.AimTo evaluate the efficacy, safety, and compliance of susceptibility-guided therapy (SGT) vs. bismuth-containing quadruple therapy (BQT) as the first-line treatment for H. pylori infection.Materials and MethodsThis meta-analysis was performed in accordance with the PRISMA 2009 guidelines. A systematic search in PubMed, Embase, and Cochrane databases was conducted using the combination of “H. pylori or H. pylori or Hp,” “bismuth quadruple,” and “tailored eradication OR tailored therapy OR susceptibility-guided therapy OR personalized therapy OR antibiotic susceptibility testing.”ResultsFive studies with 2,110 H. pylori-infected patients were enrolled. The pooled eradication rates of SGT and BQT were 86 vs. 78% (p < 0.05) and 92 vs. 86% (p > 0.05) by intention-to-treat (ITT) and per-protocol (PP) analyses, respectively. SGT has a significantly superior efficacy than BQT [pooled risk ratio (RR) = 1.14, p < 0.05] in a subgroup of cultures with the susceptibility test. The pooled side effect rate was 20% in SGT and 22% in BQT, which showed no significant difference (p > 0.05). The compliances of SGT and BQT were 95 and 92%, respectively.ConclusionCompared with BQT, SGT showed a higher efficacy and similar safety as the first-line treatment of H. pylori infection in areas with high antibiotic resistance. The decision-making of first-line regimens for H. pylori infection should depend on the availability and cost-effectiveness of susceptibility tests and bismuth in local areas.

Optimizing Helicobacter pylori Treatment: An Updated Review of Empirical and Susceptibility Test-Based Treatments

“…The pooled eradication rate of BQT was significantly higher (86% vs 78%, p<0.05). 115 A recent meta-analysis combined 54 clinical studies to examine the efficacy of tailored therapy as first-and second-line therapy. 116 In this study, tailored therapy had a significantly higher eradication success rate than that of empirical therapy in an integrated analysis that included all eradication regimens (86% vs 76%: RR, 1.12; 95% CI, 1.08 to 1.17).…”

Susceptibility‐guided sequential strategy versus empirical therapy for Helicobacter pylori infection: study protocol for a randomised controlled trial

“…A meta-analysis suggested that susceptibility-guided therapy (SGT) may be slightly superior to empirical first-line triple therapy; however, SGT does not appear to be superior to empirical first-line quadruple therapy or empirical rescue therapy [ 11 ]. Another meta-analysis revealed that, compared with bismuth-containing quadruple therapy (BQT), SGT showed similar efficacy to the first-line treatment of H. pylori infection in areas with high antibiotic resistance [ 12 ]. A limitation of RCTs is that many comparative studies evaluating SGT versus empirical treatment included susceptibility testing for only one antibiotic (clarithromycin); metronidazole susceptibility was assessed only in some cases, and quinolone resistance was only exceptionally evaluated [ 9 ].…”

“…A meta-analysis reported that the overall eradication rate in patients harbouring susceptible strains was 95.0% (95% CI [94.1–95.9]), but only 63.4% of treatment arms (64/101) achieved good eradication rates (≥ 90%) [ 14 ]. Furthermore, almost every RCT study on AST of H. pylori only included either first-line or rescue therapies [ 11 , 12 , 14 – 16 ].…”

Quantitative PCR of string‐test collected gastric material: A feasible approach to detect Helicobacter pylori and its resistance against clarithromycin and levofloxacin for susceptibility‐guided therapy

“…Further, the H. pylori clinical isolates in southern China patients who failed first‐line therapy were highly resistant to metronidazole, clarithromycin, and levofloxacin, at 93.7%, 34.3%, and 39.8%, respectively 9 . Therefore, it is logical that the antibiotic susceptibility‐guided treatment strategy should be adopted to avoid the use of ineffective antibiotics when treating potentially resistant organisms, thereby improving the treatment success rate 10 …”

“…9 Therefore, it is logical that the antibiotic susceptibility-guided treatment strategy should be adopted to avoid the use of ineffective antibiotics when treating potentially resistant organisms, thereby improving the treatment success rate. 10 While the phenotypic agar dilution method and Epsilometer test (E-test) remain the current gold standards for determining H. pylori antibiotic resistance profiles, their invasive, skill-dependent, and time-consuming natures attributed to the need of gastric biopsy specimens for the isolation and culturing of this fastidious and slow-growing organism hinder the wide-spread application of susceptibility-guided therapy in actual clinical settings. 11 Consequently, different molecular genetic testing methods such as the use of qPCR to detect 23S rRNA and gyrA mutations conferring clarithromycin and levofloxacin resistance, respectively, had been developed.…”