Quadruple therapy as first choice for eradication of H. pylori due to clarithromycin-resistance

Helicobacter pylori is associated with benign and malignant diseases of the upper gastrointestinal tract. Increasing antibiotic resistance has made alternative treatments necessary.

Diagnosis of Helicobacter pylori infection: 13C urea breath test or the stool antigen test as “test and treat strategy”. BMJ, 2012.

Empirical triple therapy (proton-pump inhibitor, clarithromycin, amoxicillin) is currently the first choice for eradication of Helicobacter pylori. As antibiotic resistance to clarithromycin (which has a crucial role in eradication) has increased. The eradication rate with triple therapy has gradually decreased below 80%, and even less.

The aim of this study reported in The Lancet was to assess the efficacy and safety of a new, single-capsule treatment versus the gold standard for H. pylori eradication (triple therapy).

A randomised, open-label trial of adults with H. pylori infection compared the efficacy and safety of:

- quadruple therapy: 10 days of quadruple therapy with omeprazole plus a single three-in-one capsule containing bismuth, metronidazole, and tetracycline

- standard therapy: 7 days of omeprazole, amoxicillin, and clarithromycin (editor note: why not 14 days of therapy?)

H. pylori eradication was established by negative 13C urea breath tests at 28 and 56 days after the end of treatment.

The eradication rates were 80% in the quadruple therapy group versus 55% in the standard therapy group.

The study authors concluded that quadruple therapy should be considered for first-line treatment in view of the rising prevalence of clarithromycin-resistant H. pylori. Quadruple therapy provides superior eradication with similar safety and tolerability to standard therapy.


Helicobacter pylori eradication with a capsule containing bismuth subcitrate potassium, metronidazole, and tetracycline given with omeprazole versus clarithromycin-based triple therapy: a randomised, open-label, non-inferiority, phase 3 trial. The Lancet, Volume 377, Issue 9769, Pages 905 - 913, 12 March 2011.

Quadruple or triple therapy to eradicate H pylori. The Lancet, Volume 377, Issue 9769, Pages 877 - 878, 12 March 2011.

H. pylori eradication provides benefits to patients with functional dyspepsia http://goo.gl/UwxsT

H. pylori image courtesy of www.hpylori.com.au.

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