Bismuth-Based Therapies for Helicobacter pylori After Initial Failure

Summary and Comment |
July 8, 2013

Bismuth-Based Therapies for Helicobacter pylori After Initial Failure

  1. David J. Bjorkman, MD, MSPH (HSA), SM (Epid.)AU058

Four quadruple therapy regimens were effective in a Chinese population with near-universal resistance to metronidazole and no resistance to other antibiotics.

  1. David J. Bjorkman, MD, MSPH (HSA), SM (Epid.)AU058

As antibiotic resistance to Helicobacter pylori increases, initial treatment failure is becoming more common, and the optimal salvage therapy for these patients remains unclear. Investigators in China evaluated the efficacy of four bismuth-based therapies in 424 patients with H. pylori infection who failed initial triple therapy (metronidazole with clarithromycin or amoxicillin, or both). Nearly half of patients failed an additional levofloxacin-containing therapy. Patients were randomized to a 2-week regimen of lansoprazole (30 mg) and bismuth potassium citrate (220 mg) twice daily, and one of the following:

  • Tetracycline (500 mg) and metronidazole (400 mg) 4 times daily (LBTM)

  • Tetracycline (500 mg) 4 times daily and furazolidone (100 mg) 3 times daily (LBTF)

  • Amoxicillin (1 g) 3 times daily and tetracycline (500 mg) 4 times daily (LBAT)

  • Amoxicillin (1 g) and furazolidone (100 mg) 3 times daily (LBAF)

Eradication was determined by a urea breath test 6 weeks after completion of therapy.

The intention-to-treat response rates were 87.9% for LBTM, 91.7% for LBTF, 83.8% for LBAT and 95.2% for LBAF. All per-protocol eradication rates were >90%. The eradication rate was higher with furazolidone-based regimens versus non–furazolidone-based regimens (P=0.01). The LBTM group had the highest rate of adverse effects (33.6%). In antimicrobial sensitivity analysis of 188 patients, 96.8% were resistant to metronidazole but not to the other antibiotics.


The authors concluded that all four bismuth-based treatments are effective in patients who failed initial therapy for H. pylori infection and are metronidazole-resistant. This is consistent with prior recommendations for bismuth-based quadruple therapy as salvage therapy. Although per-protocol eradication rates exceeded 90%, intention-to-treat analyses showed only the furazolidone-containing regimens exceeding this threshold. Results might not be generalizable outside of this single-center population with near-universal metronidazole resistance and lack of resistance to other antibiotics. Also, furazolidone is not available in many countries. Identification of the optimal regimen will require additional studies in different areas of the world, which have different antibiotic resistance patterns. Moreover, the optimal regimen may differ based on local resistance patterns and antibiotic availability.

Editor Disclosures at Time of Publication

  • Disclosures for David J. Bjorkman, MD, MSPH (HSA), SM (Epid.) at time of publication Leadership positions in professional societies World Gastroenterology Organization (Treasurer)


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