H. pylori: combining bismuth citrate with a nitroimidazole leads to higher cure rates than combining with amoxicillin

Clinical bottom line (level 1a)

  1. Patients with H. pylori infections who take bismuth citrate, clarithromycin and a nitroimidazole compared with bismuth citrate, clarithromycin and amoxicillin have higher cure rates.
  2. There is no clear difference in cure rates if bismuth citrate is replaced by a proton pump inhibitor.
Janssen et al: Aliment Pharmacol Ther 2001; 15 : 613-624
Expires May 2004

The study

Systematic review of all randomised controlled trials of
  • Patients: H. pylori infection
  • Intervention: triple therapy using proton pump inhibitor/bismuth citrate, clarithromycin and a nitroimidazole compared with triple therapy using proton pump inhibitor/bismuth citrate, clarithromycin and amoxicillin
  • Outcome: eradication

Articles found in English, Dutch, German or French using Medline, to August 2000 (search terms: not given ) and hand-searching abstracts from major gastroenterology meetings, and checking bibliographies of retrieved articles.

Selection criteria: see above and below
Appraisal criteria: randomisation, intention-to-treat, blinding
Articles excluded if:
  • duplicate studies
47 RCTs found

The evidence

  • bismuth citrate triple therapy: nitroimidazole v. amoxicillin: weighted difference: 6% (95% CI: 2% to 10%)
  • proton pump inhibitor triple therapy: nitroimidazole v. amoxicillin: weighted difference: 1% (95% CI: -1% to 3%)

Comments

  1. The study did not report odds ratios.

Citation

  1. Janssen MJ, van Oijen AH, Verbeek AL, et al: a systematic comparison of triple therapies for treatment of Helicobacter pylori infection with proton pump inhibitor/ ranitidine bismuth citrate plus clarithromycin and either amoxicillin or a nitroimidazole. Aliment Pharmacol Ther 2001; 15 : 613-624
Search Terms: from ACP Journal Club other articles noted
Contributor: Chris Ball, May 2002
Reviewer:

Clinical Question.
Patient H. pylori infection
Intervention or Exposure triple therapy with nitroimidazole
Comparison triple therapy with amoxicillin
Outcome eradication