A “new” option in Helicobacter pylori eradication: High‐dose amoxicillin dual therapy outperforms bismuth quadruple therapy in a high dual resistance setting

Abstract Background Currently, bismuth quadruple therapy (BQT) is indicated as a first‐line treatment for Helicobacter pylori eradication in areas with high dual metronidazole and clarithromycin resistance, with its use being limited by its low tolerability and significant cost. A novel regimen with high‐dose amoxicillin dual therapy (HDADT) has emerged as an alternative. The aim of this study was to compare the results of these two treatments on HP eradication. Materials and Methods Prospective randomized study including 100 consecutive patients undergoing H . pylori eradication. Each patient was randomized (in a 1:1 ratio) to one group of treatment: BQT (bismuth 140 mg + metronidazole 125 mg + tetracycline 125 mg, four times a day, for 10 days) or HDADT (amoxicillin 1000 mg alternating with amoxicillin 500 mg, four times a day, for 14 days), both associated with esomeprazole 40 mg twice a day. The primary aim was to compare treatments' efficacies. Secondary aims were to assess symptoms persistence and tolerability. Results A total of 100 patients were included, 54% women, with a mean age of 55 ± 14 years. From these, five were lost to follow‐up. Effective eradication proven by negative stool antigen test was significantly higher in patients randomized to HDADT when compared to BQT for both intention‐to‐treat (ITT) (96.2% vs. 81.4%; p = .022) and per‐protocol (PP) (95.9% vs. 81%; p = .025) analysis. These differences were even more pronounced when only considering second line treatment (100% vs. 62.5%; p = .028). Side effects did not differ significantly between BQT and HDADT groups for both ITT (7.0% vs. 2.0%; p = .254) and PP (4.8% vs. 0%; p = .210) analysis. Conclusions When compared to BQT, treatment with HDADT presented higher and near 100% efficacy in eradicating H . pylori , without differences in reported side effects or compliance. This treatment represents an important alternative for populations with increasing incidences of resistance to the currently recommended antibiotic regimens.