Bismuth supplements as the first-line regimen for Helicobacter pylori eradication therapy: Systemic review and meta-analysis

Background and Aims: An increase in the use of antibiotics leads to increased antibiotic resistance of Helicobacter pylori (H pylori). Consequently, it has been considered that the first-line standard regimen should be changed. The main purpose of this study was to evaluate the efficacy of nonantibiotic (bismuth) supplements as a first-line regimen for H pylori eradication. Methods: We searched PubMed, EMBASE, CINAHL, and the Cochrane Library databases for randomized controlled trials (RCTs) reported in English and undertaken up until August 2018. A meta-analysis of all randomized controlled trials comparing bismuth supplements with non-bismuth-containing regimens in H pylori eradication was performed. RCTs of classic bismuth-containing quadruple therapy as a first-line regimen were excluded. Results: We identified twenty-five randomized trials (3990 patients), and the total H pylori eradication rate, according to per protocol analyzed, was 85.8%. The odds ratio was 1.83 (95% confidence interval (CI). 1.57-2.13). Among these RCTs, there were 7 RCTs for bismuth add-on therapy, and the odds ratio was 2.81 (95% CI. 2.03-3.89). When the studies were performed in a high clarithromycin resistance area (≥15%) or included patients with clarithromycin resistance, bismuth-containing regimens were superior to non-bismuth regimens. Moreover, the incidence of total side effects was insignificant. Conclusions: Bismuth supplements as a first-line regimen could be effective, with bismuth add-on regimens being the most effective. Particularly, bismuth supplements showed the potential efficacy for clarithromycin-resistant strains and would be the most viable alternative in clinical practice.