P-CAB regimens raised eradication of clarithromycin-resistant H. pylori from 53% to 75%

Design

Systematic review and random-effects meta-analysis (randomised and non-randomised studies)

Population

Adults with documented clarithromycin-resistant H. pylori; 12 comparative studies (n = 1,192)

Primary outcome

H. pylori eradication rate

Effect

74.7% vs 52.7%; RR 1.42 (95% CI 1.14–1.76); vonoprazan RR 1.78 (1.55–2.04)

This systematic review and meta-analysis included 20 studies of adults with documented clarithromycin-resistant Helicobacter pylori. Twelve compared regimens built on a potassium-competitive acid blocker (P-CAB) with regimens built on a proton pump inhibitor (PPI).

Eradication was 74.7% (464 of 621) with P-CAB regimens and 52.7% (301 of 571) with PPI regimens (RR 1.42, 95% CI 1.14 to 1.76). Vonoprazan showed the largest effect (RR 1.78, 1.55 to 2.04); tegoprazan was also better (RR 1.26, 1.04 to 1.54). The gain was greatest when clarithromycin triple therapy was used despite resistance (RR 1.79).

Clarithromycin resistance is high in India, and susceptibility testing is rarely done. Vonoprazan is available here. The bigger lesson is not to use clarithromycin triple therapy where resistance is likely; but where acid suppression is the lever, a P-CAB performed better in this analysis.

• Where clarithromycin resistance is likely, avoid clarithromycin triple therapy regardless of the acid suppressant.
• Consider vonoprazan in place of a PPI in H. pylori eradication regimens.
• Bismuth quadruple therapy for 14 days remains a strong first-line option in high-resistance settings.
• Confirm eradication with a urea breath test or stool antigen at least 4 weeks after treatment.
• Stop PPIs and P-CABs at least 2 weeks before testing to avoid false negatives.

Why it matters

Acid suppression strength decides whether many resistant infections clear, and the stronger option is available in Indian practice.

Don't overread it

Many included studies were non-randomised, and regimens varied; the best antibiotic partner and duration are not settled.

The statistics, in plain English

A risk ratio of 1.42 means P-CAB regimens were about 42% more likely to succeed. The analysis mixed randomised and non-randomised studies, and different antibiotic combinations, so the pooled figure is an average across varied regimens.

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