UEG's educational platform for gastroenterology education bringing recordings, courses, guidelines, and more together in one place.

UEG Week Berlin 2025 Recordings Gut Guide online

Rate for better recommendations!

Your feedback helps us show you more of what you like and less of what you dislike!

More of this!

We will show you more similar content.

Not for me!

We won't suggest this again.

Bookmark!

Save this content for later!

New to myUEG? Create an account! Log In with myUEG account

UEG Poster

Standard Poster

Share via Email Share on Facebook Share on X Share on LinkedIn Share on Bluesky

This content is part of Gutflix. Log in with your myUEG account, or create one free, to watch it.

Not sure what you can access? Learn more about account types.

EMPIRICAL SECOND-LINE TREATMENTS IN EUROPE: DATA FROM 9,000 CASES FROM THE EUROPEAN REGISTRY ON HELICOBACTER PYLORI MANAGEMENT (HP-EUREG)

Olga P. Nyssen 1, Laimas Virginijus Jonaitis* 2, Ángeles Pérez-Aísa 3, Matteo Pavoni 4, Samuel Jesús Martínez-Domínguez 5, Bojan Tepes 6, Liudmila Vologzhanina 7, Giulia Fiorini 8, Irina Voynovan 9, Alfredo J. Lucendo 10, Javier Tejedor-Tejada 11, Manuel Pabon-Carrasco 12, Luis Bujanda 13, Jose Maria Huguet 14, Inmaculada Ortiz Polo 15, Frode Lerang 16, Jesús Barrio 17, Fernando Bermejo 18, Giuseppe Losurdo 19, Blas José Gómez-Rodríguez 20, Thomas Butler 21, Miguel Areia 22, Aiman Sarsenbaeva 23, Oscar Núñez Martínez 24, Ian Beales 25, Henrique Fernandes-Mendes 26, Sayar Abdulkhakov 27, Antonio Gasbarrini 28, Maja Denkovski 29, Alma Keco-Huerga 20, Monica Perona 30, Perminder S Phull 31, Georges Kamtoh 32, Sergei Alekseenko 33, Sinead Smith 34, Wojciech Marlicz 35, Juozas Kupcinskas 2, Dmitry S. Bordin 36, Marcis Leja 37, Ricardo Pinto 38, Ramón Pajares Villarroya 39, Manuel Jiménez-Moreno 40, Irene Arteagoitia 41, Mónica Sánchez Alonso 42, Anna Cano-Catala 43, Pablo Parra 1, Leticia Moreira Ruiz 44, Francis Mégraud 45, Colm O'Morain 46, Javier P. Gisbert 1

Affiliations

1 Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Madrid, Spain

2 Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania

3 Department of Gastroenterology, Hospital Universitario Costa del Sol, Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), Marbella, Spain

4 Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi University Hospital, Bologna, Italy

5 Department of Gastroenterology, Hospital Clínico Universitario Lozano Blesa, Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Zaragoza, Spain

6 Department of Gastroenterology, DC Rogaska, Rogaska Slatina, Slovenia

7 Gastrocentr, Perm, Russian Federation

8 Cardiovascular Medicine Unit, Heart, Chest and Vascular Dept., IRCCS Azienda Ospedaliero-Universitaria di Bologna, Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Dept., Alma Mater Studiorum University of Bologna, Bolog

9 A.S. Loginov Moscow Clinical Scientific Center, Moscow, Russian Federation

10 Department of Gastroenterology, Hospital General de Tomelloso, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Tomelloso, Spain

11 Department of Gastroenterology, Hospital Universitario de Cabueñes, Asturias, Spain

12 Department of Gastroenterology, Hospital Universitario Virgen de Valme, Sevilla, Spain

13 Department of Gastroenterology, Biodonostia Health Research Institute, Department of Medicine, Universidad del País Vasco (UPV/EHU), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), San Sebastián, Spain

14 Department of Gastroenterology, Hospital General Universitario de Valencia, Valencia, Spain

15 Department of Gastroenterology, Hospital Universitario y Politécnico la Fe, Valencia, Spain

16 Østfold Hospital Trust, Grålum, Norway

17 Department of Gastroenterology, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain

18 Department of Gastroenterology, Hospital Universitario de Fuenlabrada, Madrid, Spain

19 Department of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy

20 Department of Gastroenterology, Hospital Universitario Virgen Macarena, Sevilla, Spain

21 Clinical Medicine, Trinity College Dublin, Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland

22 Department of Gastroenterology, Portuguese Oncology Institute of Coimbra, Faculty of Medicine of the University of Porto (FMUP), RISE@CI-IPO (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto), Coimbra, Portugal

23 Department of Gastroenterology, Chelyabinsk Regional Clinical Hospital, Chelyabinsk, Russian Federation

24 Department of Gastroenterology, Hospital Universitario La Moraleja, Faculty of Medicine, Universidad Francisco de Vitoria, Faculty of Medicine, Universidad CEU San Pablo, Madrid, Spain

25 Norwich Medical School, University of East Anglia, Norwich, United Kingdom

26 Department of Gastroenterology, Centro Hospitalar Universitário de Santo António, ULS de Santo António, Porto, Portugal

27 Kazan (Volga region) Federal university, Kazan State Medical University, Kazan, Russian Federation

28 Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy

29 Interni oddelek, Diagnostic Centre, Bled, Slovenia

30 Department of Gastroenterology, Hospital Quirón Marbella, Marbella, Spain

31 Department of Digestive Disorders, Aberdeen Royal Infirmary, Aberdeen, United Kingdom

32 Hepatic Medical, Private Medical Center, Krakow, Poland

33 Far Eastern State Medical University, Khabarovsk, Russian Federation

34 School of Medicine, Trinity College Dublin, Dublin, Ireland

35 Department of Gastroenterology, Pomeranian Medical University in Szczecin, The Centre for Digestive Diseases, Endoklinika, Szczecin, Poland

36 Department of Pancreatic, Biliary and upper digestive tract disorders, A. S. Loginov Moscow clinical scientific center, Department of outpatient therapy and family medicine, Moscow, Russian Federation

37 Department of Gastroenterology, Digestive Diseases Centre, Institute of Clinical and Preventive Medicine, University of Latvia, Riga, Latvia

38 Department of Gastroenterology, Centro Hospitalar do Porto, Instituto De Ciências Biomédicas de Abel Salazar, Universidade do Porto, Center for Research in Health Technologies and Information Systems (CINTESIS), Porto, Portugal

39 Department of Gastroenterology, Hospital Universitario Infanta Sofía, Faculty of Medicine, Universidad Europea de Madrid, Madrid, Spain

40 Department of Gastroenterology, Hospital Universitario de Burgos, Burgos, Spain

41 Department of Gastroenterology, Hospital Universitario de Cruces, Vizcaya, Spain

42 Department of Gastroenterology, Hospital Universitario Santa Bárbara, Ciudad Real, Spain

43 Gastrointestinal Oncology, Endoscopy and Surgery (GOES) research group, Althaia Xarxa Assistencial Universitària de Manresa, Institut de Recerca i Innovació en Ciències de la Vida i de la Salut de la Catalunya Central (IRIS-CC), Manresa, Spain

44 Department of Gastroenterology, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelon

45 INSERM U1312 BRIC, Université de Bordeaux, Bordeaux, France

46 Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland

Summary

AI Generated

A prospective European registry of 8,901 patients found that empirical second-line H. pylori therapy achieved 82% overall effectiveness, with bismuth quadruple regimens prescribed for 14 days with high-dose PPIs exceeding 90% cure rates.

Overall second-line empirical therapy effectiveness was 82% by both modified intention-to-treat and per-protocol analysis, with 96.5% patient compliance and adverse events in 19% of cases, most mild.
Bismuth quadruple therapies with either tetracycline-metronidazole or clarithromycin-amoxicillin prescribed for 14 days with high-dose PPIs provided over 90% success rates.
After first-line clarithromycin-containing therapy failure, optimised bismuth quadruple therapy with clarithromycin-amoxicillin achieved 92% cure rate, while amoxicillin-metronidazole achieved 91%.
After failure of bismuth quadruple therapy, bismuth quadruple therapy with clarithromycin-amoxicillin achieved 95% to 95.5% cure rates depending on prior regimen format.
The authors conclude that optimization of regimen selection, treatment duration, and PPI dosing is necessary after first-line therapy failure.

Download PDF

Was this helpful?

Thanks for your feedback.

This summary was generated by an AI large language model based on the content transcript. It is for informational purposes only and should not be considered a substitute for clinical judgment. Always rely on your professional expertise and the full clinical context when making clinical decisions.

Abstract

Introduction

After a first eradication attempt, a relevant proportion of patients fail to cure Helicobacter pylori infection.

Aims & Methods

To evaluate the effectiveness of second-line empirical treatment.
A systematic, prospective, registry of the clinical practice of European gastroenterologists (38 countries) on H. pylori management was established (Hp-EuReg, Hp-WorldReg’s partner). All infected adult patients were systematically registered at AEG-REDCap e-CRF until January 2025. Modified intention-to-treat (mITT) and per-protocol (PP) analyses were performed.

Results

Overall, 8,901 patients received a second-line empirical therapy. Mean age was 51 years, 67% were women, and 4.7% had penicillin allergy. Most frequent treatment indications were dyspepsia (74%) and gastroduodenal ulcer (13%). Overall effectiveness was 82% (both by mITT and PP). Overall, 96.5% of patients were compliant. Adverse events were reported in 19% of the cases, most of them mild. The overall effectiveness of most frequent empirical second-line treatments is shown in Table 1, showing that uniquely bismuth quadruple therapies, either with metronidazole-tetracycline or clarithromycin-amoxicillin, when prescribed for 14 days and with high-dose PPIs provided over 90% success rates. After failure of first-line clarithromycin-containing therapy, the most effective second-line treatments were triple therapy with amoxicillin and either rifabutin or levofloxacin providing 85% and 80% effectiveness, respectively. Additionally, bismuth quadruple therapy with regimens containing tetracycline-metronidazole in single-capsule and classical formulation, with clarithromycin-amoxicillin and with levofloxacin-amoxicillin achieved 87%, 84%, 88% and 85% cure rates, respectively. Within the same subgroup but in patients receiving optimised therapy —defined as a 14-day course with standard or high-dose PPIs at >40mg omeprazole equivalent twice daily —, certain regimens yielded even higher cure rates. Among these, triple therapy with amoxicillin-levofloxacin obtained 87% success rate, while non-bismuth concomitant therapy with amoxicillin-clarithromycin-metronidazole reached 86%. Bismuth quadruple therapy with either tetracycline-metronidazole (administered either as a single capsule or in the classical prescription) reported 89% success; but with amoxicillin-metronidazole or clarithromycin-amoxicillin highest effectiveness was reported, that is, 91% and 92%, respectively. After failure of bismuth quadruple therapy either in the classical format or when prescribed as the single-capsule, bismuth quadruple therapy with clarithromycin-amoxicillin achieved 95.5% and 95% cure rates, respectively; whereas, the single capsule obtained 93% and 89%, respectively.

Table 1. Second-line empirical treatment prescriptions and effectiveness by treatment scheme and geographical region.
Treatment Triple-A+L Single-capsule* Quadruple-A+L+B Quadruple-C+A+M Quadruple-M+Tc+B Triple-C+A Quadruple-C+A+B Triple-A+R Triple-A+M Other Overall Overall (optimised conditions) East East-Centre South-West West-Centre North Total	N 2,100 1,850 1,271 553 480 436 390 218 204 1,229 8,731 1,913 1,404 1,645 4,046 1,163 643 8,901	Use (%) 24 21 14 6.2 5.4 4.9 4.4 2.4 2.3 14 100 22 16 18 45 13 7.2 100	mITT, N (%) 1,853 (79%) 1,721 (87%) 1,022 (86%) 527 (81%) 426 (84%) 344 (74%) 267 (89%) 195 (82%) 178 (57%) NA 7,601 (82%) 1,641 (87%) 1,147 (83%) 1,158 (85%) 3,834 (81%) 1,043 (84%) 566 (70%) 7,748 (82%)	(95% CI) (78-81) (85-89) (83-88) (78-85) (80-88) (69-79) (85-93) (76-87) (50-65) NA (81-83) (85-89) (81-86) (83-87) (80-83) (82-86) (66-74) (81-83)	PP, N (%) 1,831 (80%) 1,684 (88%) 1,002 (86%) 514 (82%) 407 (86%) 338 (74%) 257 (89%) 193 (82%) 177 (58%) NA 7,451 (82%) 1,604 (87%) 1,111 (84%) 1,145 (85%) 3,756 (82%) 1,028 (84%) 548 (72%) 7,588 (82%)	(95% CI) (78-82) (86-89) (84-88) (79-86) (82-89) (69-79) (86-93) (76-88) (50-65) NA (81-83) (86-89) (81-86) (83-87) (81-83) (82-87) (68-75) (81-83)
95% CI –confidence interval; mITT: modified intention-to-treat; PP: per-protocol, N: total number of patients analysed; C – clarithromycin; M – metronidazole; A – amoxicillin; L – levofloxacin; B – bismuth salts; Tc – tetracycline; R – rifabutin; Other – Other second-line empirical treatments with less than 150 patients treated in each category; East – Ukraine, Serbia, Bulgaria, Turkey, Russia, Romania, Albania, North Macedonia, Bosnia and Herzegovina, Kosovo, Moldova, Montenegro; East-Centre – Croatia, Poland, Hungary, Latvia, Lithuania, Greece, Slovenia, Czech Rep, Azerbaijan, Slovakia, Malta, Armenia; South-West – Portugal, Spain; West-Centre – France, Austria, Belgium, Germany, Italy; North – The United Kingdom, Finland, The Netherlands, Ireland, Israel, Norway, Switzerland, Sweden, Denmark; three-in-one single-capsule containing tetracycline, metronidazole and bismuth; *achieved over 90% effectiveness when optimised (high-dose PPIs and 14-days).

Conclusion

In Europe, empirical second-line treatment overall effectiveness is generally suboptimal (<90%); however, successful results were obtained with bismuth quadruple therapies, either with tetracycline-metronidazole or clarithromycin-amoxicillin, when prescribed for 14 days and with high-dose PPIs. Optimization of regimen selection, treatment duration, and PPI dosing is necessary after first-line therapy failure.

Disclosure

Javier P. Gisbert has served as speaker, consultant, and advisory member for or has received research funding from: Mayoly, Allergan/Abbvie, Diasorin, Richen, Juvisé and Biocodex.
Olga P. Nyssen received research funding from: Mayoly, Allergan/Abbvie, Richen, Juvisé and Biocodex.

Conference

UEG Week Berlin 2025

Topics

Stomach & H. Pylori

Submission format

Abstract

Session

H. pylori: Real world data (Posters)

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

More Like This:

MASLD with Sven Francque - Part 1

Pradeep Mundre

HISTOPATHOLOGICAL CORRELATIONS OF TISSUE SOUND SPEED IN HEPATOCELLULAR CARCINOMA: A QUANTITATIVE ASSESSMENT USING ACOUSTIC MICROSCOPY

Hideki Ishizu

IMPACT OF PROBIOTICS ON GUT MICROBIOTA AND METABOLOME DURING HIGH-DOSE DUAL THERAPY WITH VONOPRAZAN AND AMOXICILLIN AS HELICOBACTER PYLORI RESCUE THERAPY: A PROSPECTIVE, MULTICENTER, RANDOMIZED CONTROLLED STUDY

Wei Jiang

PAPILLARY LARGE BALLOON DILATATION VERSUS ENDOSCOPIC COMPLETE SPHINCTEROTOMY IN PATIENTS WITH LARGE COMMON BILE DUCT STONE(S) AND PERIAMPULLARY DIVERTICULUM

Mohammed Ahmed Hasuna Hemeda

ROLE OF ENDOSCOPIC BILIARY STENTING IN ACCESS TO CHEMOTHERAPY IN PATIENTS WITH UNRESECTABLE MALIGNANT OBSTRUCTION

Malgorzata Janik

FROM BURN TO TREATMENT: REVISITING THE NATURAL HISTORY OF PEPTIC ULCER DISEASE - A TERTIARY CENTER EXPERIENCE

Pedro Narra Figueiredo

UEG Podcast Episode

UEG Podcast

Share via Email Share on Facebook Share on X Share on LinkedIn Share on Bluesky

This content is part of Gutflix. Log in with your myUEG account, or create one free, to watch it.

Not sure what you can access? Learn more about account types.