Randomised controlled trial: susceptibility‐guided therapy versus empiric bismuth quadruple therapy for first‐line Helicobacter pylori treatment

Summary Background Increasing Helicobacter pylori resistance has led to decreases in treatment effectiveness. Aim To test the effectiveness of susceptibility‐guided therapy vs a locally highly effective empiric modified bismuth quadruple therapy for first‐line H pylori treatment in a region with high antimicrobial resistance . Methods We compared 14‐day susceptibility‐guided with empiric therapy using a multicentre superiority‐design trial, which randomised H pylori infected subjects 3:1 to (a) susceptibility‐guided therapies contained esomeprazole 20 mg and amoxicillin 1 g b.d. plus clarithromycin 500 mg, metronidazole 400 mg b.d., or levofloxacin 500 mg daily for susceptible infections or bismuth 220 mg b.d. and metronidazole 400 mg q.d.s. for triple‐resistant infections; (b) Empiric therapy contained esomeprazole 20 mg, bismuth 220 mg b.d., amoxicillin 1 g and metronidazole 400 mg t.d.s. Primary outcome was H pylori eradication. Results Between February 2017 and March 2018, 491 subjects were screened and 382 were randomised. Both the susceptibility‐guided and the empiric regimens were highly successful with per‐protocol eradication rates of 97.7% (250/256) vs 97.6% (81/83, P = 1.00) and intent‐to‐treat eradication rates of 91.6% (262/286) vs 85.4% (82/96, P = 0.12). Overall, susceptibility‐guided therapy was not superior to empiric therapy with 0.1% per‐protocol (95% CI −3.1% to 3.2%) and 6.2% intent‐to‐treat (−0.3% to 12.7%) eradication difference. Both approaches had high adherence and low adverse event rates. Conclusions Both susceptibility‐guided and empiric therapies provided excellent eradication rates. Clinically, the choice would hinge on availability of susceptibility testing and/or a locally highly effective empiric therapy.