H. pylori: a proton-pump inhibitor and 2 antibiotics are most effective at eradication

Clinical bottom line (level 1a)

  1. Triple therapy is more effective than dual therapy at eradicating H. pylori infection.
  2. Proton-pump triple therapy (a proton pump inhibitor plus 2 of amoxicillin, clarithromycin or a nitroimidazole) is most effective at eradicating H. pylori.
Penston and McColl: British Journal of Clinical Pharmacology 1997; 43: 223-243
Expires November 2002

The study

Systematic review of any papers or abstracts reporting eradication rates of
  • Patients: H. pylori infection
  • Intervention: H. pylori eradication regimens
  • Outcome: H. pylori eradication on testing 1 month after therapy

Articles found in ?English using Medline, 1990 to 1995 (search terms: not given ) and and hand-searching abstracts from international gastroenterology conferences

Selection criteria:
Appraisal criteria:
Articles excluded if:
  • review articles
  • inadequate data
  • regimens unspecified
  • pooled analysis from 2 separate regimens
  • duplicate publications
  • assessment of eradication < 1 months after therapy completed


352 studies found

The evidence

  • dual therapy eradication rate
    • omeprazole plus amoxicillin: 61% (95% CI: 59% to 62%)
    • omeprazole plus clarithromycin: 70% (95% CI: 68% to 72%)
    • lansoprazole plus amoxicillin: 48% (95% CI: 40% to 57%)
    • lansoprazole plus clarithromycin: 55% (95% CI: 49% to 61%)
    • ranitidine plus amoxicillin: 46% (95% CI: 38% to 54%)
    • ranitidine plus clarithromycin: 59% (95% CI: 46% to 72%)
  • triple therapy
    • bismuth compound plus a nitroimidazole plus tetracycline: 79% (95% CI: 77% to 80%)
    • bismuth compound plus a nitroimidazole plus amoxicillin: 71% (95% CI: 68% to 73%)
    • bismuth compound plus a nitroimidazole plus tetracycline plus a proton-pump inhibitor: 83% (95% CI: 80% to 86%)
    • bismuth compound plus a nitroimidazole plus amoxicillin plus a proton-pump inhibitor: 79% (95% CI: 74% to 83%)
  • proton-pump inhibitor triple therapy: proton-pump inhibitor plus 2 antibiotics (from amoxicillin, clarithromycin or a nitroimidazole): 87% (95% CI: 86% to 87%)
  • H-2 receptor antagonist triple therapy: H-2 receptor antagonist plus 2 antibiotics (from amoxicillin, clarithromycin or a nitroimidazole): 72% (95% CI: 68% to 75%)

Comments

  1. Duration of eradication varied between 1 and 2 weeks without much variation in efficacy.
  2. 3% of patients on dual or triple therapy had to withdraw due to intolerable side-effects.
  3. After the Maastricht 2-2000 Consensus conference, the PPI triple therapy for 1 week is almost the best therapy, with a little change: the dose of clarithromycin should be 500 mg bid in every regime.

Citation

  1. Penston JG, and McColl KE: eradication of Helicobacter pylori: an objective assessment of current therapies. British Journal of Clinical Pharmacology 1997; 43: 223-243
Search Terms:
Contributor: Chris Ball and Musab Hayatli, November 1999
Reviewer: Horand Meier

Clinical Question.
Patient H. pylori infection
Intervention or Exposure eradication therapy
Outcome eradication at 1 month