Empirical vs. Susceptibility-Guided Treatment of Helicobacter pylori Infection: A Systematic Review and Meta-Analysis

BACKGROUND: Treating Helicobacter pylori infection according to antibiotic resistance has been frequently recommended. However, information on its real effectiveness is scarce. AIM: The aim of this study is to perform a meta-analysis comparing empirical vs. susceptibility-guided treatment of H. pylori. METHODS: Selection of studies: Studies comparing empirical versus susceptibility-guided treatment were selected. Search strategy: electronic and manual up to August 2021. Data synthesis: by intention-to-treat (random-effects model). RESULTS: Overall, 54 studies were included (6,705 patients in the susceptibility-guided group and 7,895 in the empirical group). H. pylori eradication rate was 86 vs. 76%, respectively (RR: 1.12; 95% CI: 1.08–1.17; I(2): 83%). Similar results were found when only RCTs were evaluated (24 studies; RR: 1.16; 95% CI: 1.11–1.22; I(2): 71%) and when susceptibility testing was assessed by culture (RR: 1.12; 95% CI: 1.06–1.18) or PCR (RR: 1.14; 95% CI: 1.05–1.23). For first-line treatments (naïve patients; 30 studies), better efficacy results were obtained with the susceptibility-guided strategy (RR: 1.15; 95% CI: 1.11–1.20; I(2): 79%). However, for empirical first-line quadruple regimens, in particular (both with and without bismuth, excluding the suboptimal triple therapies), not based on CYP2C19 gene polymorphism, no differences in efficacy were found compared with the susceptibility-guided group (RR: 1.04; 95% CI: 0.99–1.09); this lack of difference was confirmed in RCTs (RR: 1.05; 95% CI: 0.99–1.12). For rescue therapies (13 studies, most 2(nd)-line), similar results were demonstrated for both strategies, including all studies (RR: 1.09; 95% CI: 0.97–1.22; I(2): 82%) and when only RCTs were considered (RR: 1.15; 95% CI: 0.97–1.36). CONCLUSION: The benefit of susceptibility-guided treatment over empirical treatment of H. pylori infection could not be demonstrated, either in first-line (if the most updated quadruple regimens are prescribed) or in rescue therapies.