Finally, it is bismuth's time.

Sir,

In an interesting Turkish retrospective study, conducted between 2012 and 2015, involving 1510 adults, Kekilli et al.[1] tested triple therapy (lansoprazole 30 mg b.i.d., clarithromycin 500 mg b.i.d., and amoxicillin 1 g b.i.d.), bismuth group C (lansoprazole, clarithromycin, amoxicillin, and bismuth subsalicylate 524 mg b.i.d.), and bismuth group M (lansoprazole, amoxicillin, metronidazole 500 mg t.i.d., and bismuth) for 14 days as first line treatment for Helicobacter pylory infection. H. pylori eradication was achieved in (per-protocol analysis) 64.7% of the patients in the triple therapy group, 95.4% in the bismuth group C, and 93.9% in the bismuth group M. Intolerable side effects leading to interruption of therapy were rare (approximately 2–3%) and similar in the different groups.

These results are in agreement with the recently published Maastricht V Consensus Report,[2] and confirmed that clarithromycin-based triple therapy should be abandoned when the clarithromycin resistance rate is more than 15%. In regions with high clarithromycin resistance but low-to-intermediate metronidazole resistance (<40%), 14 days bismuth quadruple therapy is advised as first line treatment.[3]

In Turkey, the H. pylori clarithromycin resistance is 16.3–50% whereas metronidazole resistance is 39.2%.[2]

In 2012, in Piedmont, Northern Italy, a region with the same H. pylori antibiotic resistance of Turkey, we[4] have prospectively evaluated the H. pylori eradication rate of 182 consecutive naive patients treated with a clarithromycin-based triple therapy: The eradication rate was 73.4%, which is considered unacceptable.[5]

In conclusion, the study conducted by Kekilli et al.[1] reaffirm that triple therapy now has an unacceptable eradication failure rate and it should no more be the first choice in countries with a high H. pylori resistance rate to clarithromycin. In this context, now is the era of bismuth-based quadruple therapy as first line treatment. When available, this could be prescribed as the new formulation with bismuth, metronidazole, and tetracycline contained in a single capsule (three-in-one).[3]

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