HIGHER doses of antibiotics and bismuth did not improve Helicobacter pylori (H. pylori) treatment effectiveness, according to a large European registry study involving more than 10,000 first-line treatment records. The findings suggest that optimising treatment adherence, duration, and proton pump inhibitor co-therapy may be more valuable than increasing antimicrobial doses.
Researchers analysed data from the European Registry on H. pylori Management (Hp-EuReg), an international, prospective, non-interventional registry involving European gastroenterologists. The study included patients receiving empirical bismuth-containing quadruple therapy between 2013 and 2024.
Effectiveness was assessed using a modified intention-to-treat analysis. Overall, 10,767 first-line treatment records and 2,952 second- to sixth-line treatment records were evaluated to investigate whether different bismuth and antibiotic doses influenced eradication outcomes.
Several first-line regimens demonstrated effectiveness exceeding 90% without requiring higher-than-standard doses. Clarithromycin-amoxicillin-bismuth therapy achieved over 90% effectiveness with amoxicillin 2,000 mg/day and clarithromycin 1,000 mg/day, irrespective of bismuth dosage.
Similarly, bismuth-metronidazole-tetracycline therapy exceeded 90% effectiveness with tetracycline doses of at least 1,500 mg/day, metronidazole 1,500 mg/day, and bismuth doses of at least 480 mg/day. Amoxicillin-metronidazole-bismuth therapy achieved approximately 90% effectiveness with amoxicillin 2,000 mg/day, metronidazole doses of at least 1,000 mg/day, and bismuth 480 mg/day.
Clarithromycin-metronidazole-bismuth therapy also achieved at least 90% effectiveness with metronidazole doses of at least 800 mg/day, without additional benefit from increasing bismuth. Furthermore, amoxicillin-levofloxacin-bismuth therapy exceeded 90% effectiveness, with no improvement when levofloxacin exceeded 500 mg/day.
For second- to sixth-line treatments, effectiveness remained below 90% across all evaluated regimens. Rates ranged from 63% for metronidazole-doxycycline-bismuth therapy to 88% for both clarithromycin-amoxicillin-bismuth and amoxicillin-metronidazole-bismuth therapies. No significant differences emerged according to bismuth dosage.
The researchers concluded that escalating antibiotic or bismuth doses beyond standard levels did not improve H. pylori treatment effectiveness. Instead, adherence, treatment duration, and proton pump inhibitor co-therapy may represent more influential factors in optimising eradication outcomes.
These findings highlight the importance of considering treatment delivery and supporting factors when managing H. pylori infection, rather than routinely increasing antimicrobial doses.
Martínez-Domínguez SJ et al. Higher doses of bismuth and antibiotics do not improve Helicobacter pylori treatment effectiveness: results from the European Registry on Helicobacter pylori management. Clin Gastroenterol Hepatol. 2026;24(11):2978-89.
Featured Image: abhijith3747 on Adobe Stock
Each article is made available under the terms of the Creative Commons Attribution-Non Commercial 4.0 License.
