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Global eradication rates for Helicobacter pylori infection: systematic review and meta-analysis of sequential therapy

BMJ 2013; 347 doi: (Published 07 August 2013) Cite this as: BMJ 2013;347:f4587
  1. Luigi Gatta, physician and gastroenterologist12,
  2. Nimish Vakil, clinical professor of medicine3,
  3. Dino Vaira, professor of internal medicine4,
  4. Carmelo Scarpignato, professor of pharmacology and therapeutics; associate professor of gastroenterology2
  1. 1Gastroenterology and Endoscopy Unit, Versilia Hospital, Lido di Camaiore, Italy
  2. 2Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
  3. 3Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
  4. 4Department of Medical and Surgical Sciences, University of Bologna, Italy
  1. Correspondence to: L Gatta, Clinical Pharmacology and Digestive Pathophysiology Unit, Department of Clinical and Experimental Medicine, University of Parma, 43125 Parma, Italy gattalg{at}
  • Accepted 10 July 2013


Objective To do a systematic review and meta-analysis of studies comparing sequential therapy for eradication of Helicobacter pylori with pre-existing and new therapies, thus providing a glimpse of eradication success worldwide.

Design Systematic review and meta-analysis.

Data sources Medline, Embase, and Cochrane Central Register of Controlled Trials up to May 2013; abstract books of major European, American, and Asian gastroenterological meetings.

Study selection Randomised controlled trials in previously untreated adults, in which sequential therapy was compared with a pre-existing or new therapy.

Results 46 randomised controlled trials were reviewed and analysed. 5666 patients were randomised to sequential therapy and 7866 to other (established and new) treatments. The overall eradication rate of sequential therapy was 84.3% (95% confidence interval 82.1% to 86.4%). Sequential therapy was superior to seven day triple therapy (relative risk 1.21, 95% confidence interval 1.17 to 1.25; I2=29.3%; number needed to treat 6 , 95% confidence interval 5% to 7%), marginally superior to 10 day triple therapy (1.11, 1.04 to 1.19; I2= 67.2%; NNT 10, 7 to 15), but not superior to 14 day triple therapy (1.00, 0.94 to 1.06; I2=54.3%), bismuth based therapy (1.01, 0.95 to 1.06; I2=21.1%), and non-bismuth based therapy (0.99, 0.94 to 1.05; I2=52.3%). Data on eradication according to pre-treatment antimicrobial susceptibility testing were available in eight studies, and sequential therapy was able to eradicate 72.8% (61.6% to 82.8%) of the strains resistant to clarithromycin.

Conclusions Eradication rates with pre-existing and new therapies for H pylori are suboptimal. Regional monitoring of resistance rates should help to guide treatment, and new agents for treatment need to be developed.


  • We are grateful to the following investigators for providing information from their studies: F Franceschi (Rome, Italy), E R Greenberg (Seattle, USA), J Molina-Infante (Caceres, Spain), J M Liou (Taipei, Taiwan), J W Chung (Incheon, Korea), M Singh (Sabah, Malaysia), H Sardarian (Sari, Iran), P N Kalapothakos (Sparti, Greece), M Lahbabi (Fez, Morocco), K Liu (Hong Kong, China), T L Ang (Singapore), A Zullo (Rome, Italy), V Yep-Gamarra (Trujillo, Peru).

  • Contributors: LG, CS, NV, and DV conceived the study. LG, CS, and DV collected the data. LG and CS analysed and interpreted the data and drafted the manuscript. All authors commented on the drafts and approved the final draft. LG is the guarantor.

  • Funding: None.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; CS has received consulting fees for advisory committees or review panels from Pfizer, Janssen-Cilag, and Sidem and for speaking and teaching from AstraZeneca; NV has received consulting fees for speaking and teaching from AstraZeneca, Takeda, Ironwood, and Otsuka and has ownership interest (stock shareholder) in Meridian Diagnostics and Orexo; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not needed.

  • Data sharing: No additional data available.

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