Metronidazole-based quadruple versus standard triple therapy: Which is better as first-line therapy for Helicobacter pylori eradication?

The eradication rate of 7-day standard triple therapy for Helicobacter pylori eradication (a proton pump inhibitor combined with amoxicillin and clarithromycin) has decreased as a consequence of the increase in the resistance rates to clarithromycin. The authors of the article under evaluation conducted a multicenter, randomized, noninferiority, Phase III trial in Europe to compare the efficacy and safety of a 10-day treatment with omeprazole plus a single capsule containing bismuth subcitrate potassium, metronidazole and tetracycline (quadruple therapy) versus a 7-day treatment with omeprazole, amoxicillin and clarithromycin (standard triple therapy) in adults, and demonstrated that the quadruple therapy yielded superior H. pylori eradication rates compared with the standard triple therapy. The results suggest that quadruple therapy merits consideration as first-line eradication therapy for H. pylori in regions with high resistance rates to clarithromycin. However, several issues need to be considered, such as the optimal doses of bismuth and amoxicillin, as well as the treatment duration, before quadruple therapy can be established as the standard first-line therapy for H. pylori eradication.