AUTHOR=Nyssen Olga P. , Espada Marta , Gisbert Javier P. 

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

JOURNAL=Frontiers in Microbiology

VOLUME=Volume 13 - 2022

YEAR=2022

URL=https://www.frontiersin.org/journals/microbiology/articles/10.3389/fmicb.2022.913436

DOI=10.3389/fmicb.2022.913436

ISSN=1664-302X

ABSTRACT=Background: Treating Helicobacter pylori infection according to antibiotic resistances has been frequently recommended. However, information on its real effectiveness is scarce. 
Aim: To perform a meta-analysis comparing empirical versus susceptibility-guided treatment of H. pylori. 
Methods: Selection of studies: comparing empirical versus susceptibility-guided treatment. 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% versus 76%, respectively (RR:1.12; 95%CI:1.08-1.17; I2:83%). Similar results were found when only RCTs were evaluated (24 studies; RR:1.16; 95%CI:1.11-1.22; I2:71%), 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; I2:79%). 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 2nd-line), similar results were demonstrated for both strategies, including all studies (RR:1.09; 95%CI:0.97-1.22; I2:82%) and when only RCTs were considered (RR:1.15; 95%CI:0.97-1.36). 
Conclusions: 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.