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First-line Helicobacter pylori eradication therapies in countries with high and low clarithromycin resistance: a systematic review and network meta-analysis
  1. Yee Hui Yeo1,2,
  2. Sz-Iuan Shiu1,
  3. Hsiu J Ho1,
  4. Biyao Zou3,
  5. Jaw-Town Lin4,5,
  6. Ming-Shiang Wu6,
  7. Jyh-Ming Liou6,
  8. Chun-Ying Wu1,6,8,9,10
  9. Taiwan Gastrointestinal Disease and Helicobacter Consortium
  1. 1Division of Gastroenterology and Hepatology, Taichung Veterans General Hospital, Taichung, Taiwan
  2. 2Nuffield Department of Population Health, University of Oxford, Oxford, UK
  3. 3Blatvatnik School of Government, University of Oxford, Oxford, UK
  4. 4School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
  5. 5Center for Health Policy Research and Development, Miaoli, Taiwan
  6. 6National Cancer Institute, National Health Research Institutes, Miaoli, Taiwan
  7. 7Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
  8. 8Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
  9. 9Department of Public Health and Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
  10. 10Department of Life Sciences and Rong Hsing Research Center for Translational Medicine, National Chung-Hsing University, Taichung, Taiwan
  1. Correspondence to Professor Chun-Ying Wu, Division of Gastroenterology and Hepatology, Taichung Veterans General Hospital 1650, Sec. 4, Taiwan Boulevard, Taichung 40705, Taiwan; chun{at}


Objective To determine the optimal regimen of different first-line Helicobacter pylori eradication therapies according to the clarithromycin resistance rate.

Design Electronic search for articles published between January 2005 and April 2016. Randomised, controlled trials that reported the effectiveness of first-line eradication therapies in treatment-naïve adults were included. Two independent reviewers performed articles screening and data extraction. Network and traditional meta-analyses were conducted using the random effect model. Subgroup analyses were performed to determine the ranking of regimens in countries with high (>15%) and low (<15%) clarithromycin resistance. Data including adverse events and therapeutic cure rate were also extracted and analysed.

Results 117 trials (totally 32 852 patients) for 17 H. pylori eradication regimens were eligible for inclusion. Compared with 7-day clarithromycin-based triple therapy, sequential therapy (ST) for 14 days had the highest effectiveness (OR=3.74, 95% CrI 2.37 to 5.96). ST-14 (OR=6.53, 95% CrI 3.23 to 13.63) and hybrid therapy (HY) for 10 days or more (OR=2.85, 95% CrI 1.58 to 5.37) represented the most effective regimen in areas with high and low clarithromycin resistance, respectively. The effectiveness of standard triple therapy was below therapeutic eradication rate in most of the countries. Longer duration was associated with higher eradication rate, but with a higher risk of events that lead to discontinuation.

Conclusions ST and HY appeared to be the most effective therapies in countries with high and low clarithromycin resistance, respectively. The clinical decision for optimal regimen can be supported by referring to the rank ordering of relative efficacies stratified by local eradication rates, antibiotic resistance and safety profile.

Trial registration number CRD42015025445.


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