S2106 Enormous Variability in Bismuth Quadruple Therapy Prescriptions for Helicobacter pylori Illustrates the Need for Uniformity With an Optimized Regimen

Introduction: The American College of Gastroenterology’s 2024 guideline on Helicobacter pylori (HP) treatment lists “optimized” bismuth quadruple therapy (BQT) for 14 days as the preferred regimen for both treatment-naïve patients and refractory infections. Optimized BQT (OBQT) is defined as bismuth at least 300 mg 4 times daily, metronidazole (MNZ) 1.5-2 g total daily in 3-4 doses, tetracycline 500 mg 4 times daily (qid), and twice-daily standard dose proton pump inhibitor (PPI) for 10-14 days because lower doses of MNZ, or substitution of doxycycline for tetracycline, reduces eradication rates. There is little data from the U.S. examining how these variations affect HP eradication rates. Methods: This was an Institutional Review Board-approved retrospective review of patients with biopsy-confirmed HP infection at our academic medical center. PPI doses were converted to omeprazole equivalents. Statistical analyses, including binomial logistic regression (α = 0.05), were performed using SAS 9.4 (Cary, NC). Results: From October 16, 2023 to June 28, 2024, 265 cases were identified, 116 of which were treated with BQT. There were 19 unique combinations of BQT medication regimens. Only 32 patients (27.6%) received a regimen now considered “optimized” per 2024 ACG guidelines. Deviations from these guidelines included the following: bismuth <300 mg qid in 54 patients (46.6%); MNZ <1.5 g daily in 30 patients (25.9%); doxycycline prescription in 12 patients (10.3%); and PPI dosed once daily in 7 patients (6.0%). In the 54 patients (age 51.3 ± 15.8 years, 59.2% women) with documented test of cure, the eradication rate was 85%. Patients treated with 20 mg daily omeprazole equivalents (OME) of PPI had 80% eradication, 40 mg OME 90% eradication, and 80 mg OME 85% eradication. Patients treated with MNZ 2 g daily had higher eradication rates than those treated with 1 g MNZ daily (88.9% vs 81.3%, respectively). Those treated with tetracycline had higher eradication rates than those treated with doxycycline (86.7% vs 77.8%, respectively). None of these differences were statistically significant. Conclusion: Nineteen variations of BQT were prescribed in 116 patients, only 27.6% of which were an “optimized” regimen. Though our study was underpowered to evaluate dose-dependent response to BQT, the results illustrate the enormous variability in BQT prescribing patterns and the need for educational efforts and system-based approaches to ensure BQT is “optimized” for effective HP eradication.