Which quadruple therapy should be prescribed as first-line treatment for Helicobacter pylori infection? Results of a prospective study comparing concomitant and bismuth therapy.

BACKGROUND AND AIMS: Helicobacter pylori (H. pylori) infection is a major global health concern associated with peptic ulcer disease, chronic gastritis, mucosa-associated lymphoid tissue (MALT) lymphoma, and gastric cancer. Rising antibiotic resistance, particularly to clarithromycin and metronidazole, has reduced the efficacy of standard triple therapy, prompting guidelines to recommend quadruple regimens. This study aimed to compare the efficacy, safety, and patient adherence of concomitant quadruple therapy (QC-14) versus bismuth-based quadruple therapy (QB-10) as first-line treatments in a Moroccan population.

METHODS

In this prospective, randomized study, 86 adult outpatients with H. pylori infection confirmed by active diagnostic tests (histology, 13C-urea breath test, or stool antigen test) were enrolled between January and June 2024 at two university hospitals in Casablanca, Morocco. Patients initially identified by serology were included only if infection was subsequently confirmed by an active test. Participants were randomized to receive either QC-14 (omeprazole, amoxicillin, clarithromycin, metronidazole for 14 days) or QB-10 (omeprazole, bismuth subsalicylate, tetracycline, metronidazole for 10 days). Eradication was assessed 4-6 weeks post-treatment. Safety, adverse events, and adherence were evaluated.

RESULTS

Baseline characteristics were similar between groups. Endoscopy was performed in 69.7 % of patients, revealing erythematous gastritis in 91.6 % and peptic ulcer disease in 8.3 %. Eradication rates were 79.5 % for QB-10 and 76.1 % for QC-14 (p = 0.53). Adverse events occurred in 31.8 % (QB-10) and 23.8 % (QC-14) (p = 0.776); diarrhea was more frequent in QC-14 (15 %), while discolored stools were reported only in QB-10 (18.2 %). Adherence exceeded 93 % in both groups.

CONCLUSIONS

Both concomitant and bismuth quadruple therapies are effective, safe, and well-tolerated first-line treatments for H. pylori eradication, achieving > 75 % eradication rates. The choice of regimen may depend on local resistance patterns, cost, and patient-specific factors. Further multicenter studies with resistance profiling are warranted.