Efficacy and Safety of Modified Bismuth Quadruple Therapy for First-Line Helicobacter pylori Eradication: A...

This study aimed to evaluate the efficacy of adding bismuth to conventional triple therapy (modified bismuth quadruple therapy [mBQT]) for Helicobacter pylori treatment-naïve patients in an era of increasing eradication failure. We performed a comprehensive literature search up to December 2024 using PubMed, Embase, and the Cochrane Library to investigate mBQT's benefits. The comparative treatments were as follows: (1) triple therapy without bismuth (TT), (2) non-BQTs (sequential and concomitant), and (3) classic BQT (cBQT) containing metronidazole and tetracycline. Randomized controlled trials (RCTs) were analyzed to compare eradication rates, adverse drug events, and patient compliance between the mBQT and comparison groups. In total, 9162 and 8449 patients from 43 trials in 35 RCTs were included in the intention-to-treat and per-protocol analyses, respectively. The mBQT group had a superior pooled eradication rate compared to the TT group (84.8% vs. 74.1%, p < 0.00001, and odds ratio [OR] = 2.02 [1.61-2.55]). The mBQT showed a similar eradication rate to the non-BQT and cBQT groups (80.8% vs. 80.2%, p = 0.55, and OR = 1.09 [0.83-1.43] in the non-BQT group; 81.5% vs. 83.0%, p = 0.36, and OR = 0.84 [0.59-1.21] in the cBQT group). Regarding adverse drug events, there was no significant difference between the mBQT and comparison groups (25.4% vs. 27.5%, p = 0.53, and OR = 0.95 [0.80-1.12]). The subgroup analysis showed that patient adherence to mBQT was significantly higher than to cBQT (96.4% vs. 93.3%, p = 0.004, and OR = 1.83 [1.21-2.77]). Our meta-analysis showed that mBQT was an effective and tolerable first-line therapy for H. pylori eradication.