Comparative Effectiveness of Empiric Treatment for Helicobacter pylori in a Large, Diverse Population in the United States.

BACKGROUND & AIMS: Treatment for Helicobacter pylori in the United States remains generally empirical due to lack of antibiotic susceptibility data. However, knowledge on comparative effectiveness of different H pylori regimens in U.S. community settings remains limited.

METHODS

This retrospective cohort study compared the effectiveness of initial and salvage H pylori treatment regimens between 2000 and 2022 at Kaiser Permanente Northern California, a large, diverse, community-based healthcare system.

RESULTS

Among 26,669 initial treatments and 5389 salvage treatments prescribed for H pylori-infected individuals, 14-day regimens of PACM-14 (proton pump inhibitor/amoxicillin/clarithromycin/metronidazole) (concomitant therapy) and PBMT-14 (proton pump inhibitor/bismuth/metronidazole/tetracycline) (bismuth quadruple therapy) achieved the highest eradication rates, 89.8% and 88.3%, respectively, without a substantial decline in effectiveness over time. All regimens had significantly lower eradication rates when given as salvage treatment, with PBMT-14 achieving the highest eradication rate (69.3%). Prior use of macrolides or metronidazole significantly reduced the eradication rates of clarithromycin- or metronidazole-containing regimens, respectively (adjusted odds ratio [aOR] for PACM-14, 0.68; 95% confidence interval [CI], 0.60-0.77; aOR for PBMT-14, 0.61; 95% CI, 0.50-0.75). Repeat use of previously prescribed regimens was associated with significantly lower eradication rates (aOR for PACM-14, 0.46; 95% CI, 0.35-0.61; aOR for PBMT-14, 0.51; 95% CI, 0.39-0.67).

CONCLUSIONS

In a large, community-based U.S. population, concomitant and bismuth quadruple therapies had the highest eradication rates for H pylori for initial treatment without a substantial decline in efficacy over time, while bismuth quadruple was the most successful salvage regimen. History of macrolides or metronidazole use should be reviewed to inform treatment selection. Repeat use of previously prescribed regimens should be avoided.