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Susceptibility-Guided Versus Empirical First-Line Therapy of Helicobacter pylori Infection in Adults
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Resumo(s)
Background: Antimicrobial resistance undermines empirical first-line regimens for Helicobacter pylori. We compared susceptibility-guided therapy (SGT) versus empirical therapy in adults receiving first-line treatment, focusing on intention-to-treat (ITT) eradication. Materials and Methods: We searched MEDLINE (PubMed), Web of Science, and Scopus from inception to 30 September 2025 for randomized controlled trials (RCTs) and non-randomized comparative studies (NRS) in adults with confirmed H. pylori. Interventions included phenotypic (culture/E-test) or genotypic (PCR) SGT applied to biopsy, stool, or gastric juice specimens; comparators were empirical regimens including bismuth quadruple therapy (BQT) and non-BQT options. The primary outcome was ITT eradication. We pooled risk ratios (RR) with DerSimonian–Laird random-effects, reported I2/τ2, and derived 95% prediction intervals (PI). Subgroups were prespecified by comparator family (BQT vs. other) and specimen/method. Multi-arm studies combined empirical arms within family or split across distinct families. Results: Forty-two studies met inclusion criteria; all contributed ITT data. RCTs (k = 33) favored SGT over empirical therapy (pooled RR 1.09, 95% CI 1.05–1.13; I2 73%; 95% PI 0.92–1.30). NRS (k = 12) were directionally consistent (pooled RR 1.15, 95% CI 1.10–1.22; I2 75%; 95% PI 0.99–1.35). In RCTs, effects were neutral-to-modest vs. BQT (RR 1.03, 95% CI 0.97–1.10) and clearer vs. other empirical regimens (RR 1.12, 95% CI 1.06–1.18). Conclusions: In adult first-line therapy, SGT achieves at least non-inferior—and often superior—eradication versus empirical regimens; the incremental benefit is attenuated where BQT is standard. These findings support selective, and increasingly justified, integration of susceptibility testing in settings with clinically relevant resistance.
Descrição
Publisher Copyright: © 2026 The Author(s). Helicobacter published by John Wiley & Sons Ltd.
Palavras-chave
antimicrobial resistance bismuth quadruple therapy culture first-line Helicobacter pylori meta-analysis PCR Gastroenterology Infectious Diseases SDG 3 - Good Health and Well-being