Efficacy and safety of antibiotic regimens for Helicobacter pylori eradication: a systematic review and meta-analysis.

BACKGROUND: Helicobacter pylori infection, a global health concern, is treated with various antibiotic regimens, but rising resistance causes variable outcomes. This meta-analysis evaluated the efficacy and safety of different eradication regimens. Methods PubMed, Embase, and Web of Science were searched from inception to October 2025. Randomized and observational studies reporting eradication rates or adverse events were included. Pooled estimates were calculated using random-effects models with subgroup analyses and meta-regression. Results Fifty-seven studies (19,941 participants, 127 arms) were included. The pooled eradication rate was 83.0% (95% CI: 81.4%-84.5%; I²=87.3%). Egger's and Begg's tests indicated publication bias (both P<0.001); trim-and-fill adjusted rate was 78.1%. Subgroup analyses showed sequential (84.3%), quadruple (83.3%), and dual therapy (83.8%) achieved slightly higher rates than triple therapy (79.2%). PCAB-based regimens outperformed PPI-based (85.3% vs. 81.6%). Ten-day regimens yielded higher rates (85.9%) than 7-day (79.8%) or 14-day (82.7%). Regimens with three antibiotics (86.9%) or nitroimidazoles (84.8%) showed improved efficacy. Meta-regression identified publication year, continent, study design, and acid suppressant as heterogeneity sources (all P<0.01). For safety (54 studies, 119 arms, 5,202 events), pooled adverse event incidence was 26.1% (95% CI: 21.0%-31.9%; I²=95.3%). Sequential therapy had the highest incidence (54.1%), dual therapy the lowest (15.8%). Regimens with three antibiotics (52.6%), macrolides (29.0%), or nitroimidazoles (37.1%) were associated with more adverse events. Conclusions Eradication regimens vary in efficacy and safety; treatment selection should balance these factors. Findings require confirmation due to high heterogeneity and between-study comparisons.

SYSTEMATIC REVIEW REGISTRATION: CRD420251207695, https://www.crd.york.ac.uk/PROSPERO/view/CRD420251207695.