Design: Systematic review and meta-analysis of randomised trials
Population: 5 trials, 1,541 treatment-naive adults with H. pylori infection
Primary outcome: Intention-to-treat eradication
Effect: RR 0.996 (95% CI 0.911 to 1.089) vs bismuth quadruple therapy

A meta-analysis pooled five randomised trials, 1,541 treatment-naive patients, comparing 14 days of tegoprazan, a potassium-competitive acid blocker, plus amoxicillin with bismuth-containing quadruple therapy.

Eradication by intention to treat was essentially identical (RR 0.996, 95% CI 0.911 to 1.089), and stayed so when comparators were limited to proton pump inhibitor-based quadruple therapy (RR 0.985). Adverse events and discontinuation were generally more frequent with quadruple therapy, though safety reporting varied between trials.

For infection specialists the appeal is stewardship as much as simplicity. The regimen avoids clarithromycin and metronidazole, the two drugs to which H. pylori resistance is most common, and relies on amoxicillin, to which resistance remains low in most settings. Potent acid suppression is what makes the dual approach work.

The evidence base is five trials, and local availability of tegoprazan varies, so bismuth quadruple therapy remains a sound default where dual therapy is not accessible.

Where tegoprazan is available, consider 14-day dual therapy with amoxicillin as a first-line option
It avoids clarithromycin and metronidazole, where resistance is common
Check for penicillin allergy before choosing an amoxicillin-based regimen
Confirm eradication with a urea breath or stool antigen test at least four weeks after treatment
Keep bismuth quadruple therapy as the default where dual therapy is unavailable

Why it matters

A regimen that drops the two most resistance-prone antibiotics could ease pressure on clarithromycin.

The statistics, in plain English

A risk ratio of 0.996 means eradication rates were almost the same. The interval from 0.911 to 1.089 says the worst plausible result for dual therapy is about 9% fewer eradications, and the best about 9% more.