Saudi Journal of Gastroenterology
Home About us Instructions Submission Subscribe Advertise Contact Login    Print this page  Email this page Small font sizeDefault font sizeIncrease font size 
Users Online: 1977 

Table of Contents   
Year : 2017  |  Volume : 23  |  Issue : 2  |  Page : 127
Finally, it is bismuth's time

1 General and Specialist Medicine Department, Città della Salute e della Scienza of Turin, Turin, Italy
2 Department of Oncology, University of Torino, Torino, Italy
3 Department of Gastroenterology, Molinette Hospital, Turin, Italy

Click here for correspondence address and email

Date of Web Publication29-Mar-2017

How to cite this article:
Ribaldone DG, Saracco G, Pellicano R. Finally, it is bismuth's time. Saudi J Gastroenterol 2017;23:127

How to cite this URL:
Ribaldone DG, Saracco G, Pellicano R. Finally, it is bismuth's time. Saudi J Gastroenterol [serial online] 2017 [cited 2022 Jan 25];23:127. Available from:


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]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Kekilli M, Onal IK, Ocal S, Dogan Z, Tanoglu A. Inefficacy of triple therapy and comparison of two different bismuth-containing quadruple regimens as a firstline treatment option for helicobacter pylori. Saudi J Gastroenterol 2016;22:366-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
Malfertheiner P, Megraud F, O'Morain CA, Gisbert JP, Kuipers EJ, Axon AT, et al. Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report. Gut 2016. pii: Gutjnl-2016-312288.  Back to cited text no. 2
Pellicano R, Ribaldone DG, Fagoonee S, Astegiano M, Saracco GM, Mégraud F. A 2016 panorama of Helicobacter pylori infection: Key messages for clinicians. Panminerva Med 2016;58:304-17.  Back to cited text no. 3
Ribaldone DG, Fagoonee S, Astegiano M, Saracco G, Pellicano R. Efficacy of amoxycillin and clarithromycin-based triple therapy for Helicobacter pylori eradication: A 10-year trend in Turin, Italy. Panminerva Med 2015;57:145-6.  Back to cited text no. 4
Gisbert JP, Calvet X, O'Connor A, Mégraud F, O'Morain CA. Sequential therapy for Helicobacter pylori eradication: A critical review. J Clin Gastroenterol 2010;44:313-25.  Back to cited text no. 5

Correspondence Address:
Davide G Ribaldone
General and Specialist Medicine Department, Città della Salute e della Scienza of Turin, Turin
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjg.SJG_605_16

Rights and Permissions


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


 Article Access Statistics
    PDF Downloaded134    
    Comments [Add]    

Recommend this journal