The efficacy of culture‐guided versus empirical therapy with high‐dose proton pump inhibitor as third‐line treatment of Helicobacter pylori infection: A real‐world clinical experience

Background and Aim Most consensuses recommend culture‐guided therapy as third‐line Helicobacter pylori treatment. This study aimed to investigate the efficacies of culture‐guided therapy and empirical therapy with high‐dose proton pump inhibitor (PPI) in the H. pylori third‐line treatment. Methods Between August 2012 and October 2021, H. pylori‐infected patients with at least two failed eradication attempts received anti‐H. pylori therapy according to the results of antimicrobial sensitivity tests plus high‐dose rabeprazole and/or bismuth. They were categorized into three groups: patients who had positive results of culture with equal to or more than three susceptible antibiotics were treated by culture‐guided non‐bismuth quadruple therapy, patients who had positive results of culture with one or two susceptible antibiotics were treated by culture‐guided bismuth‐containing therapy, and patients who had a negative result of culture were treated by an empirical therapy with high‐dose rabeprazole plus amoxicillin, tetracycline and levofloxacin. A post‐treatment assessment was conducted at week 8. Results We recruited 126 patients. The eradication rates of culture‐guided non‐bismuth quadruple therapy (n = 50), culture‐guided bismuth‐containing therapy (n = 46) and empirical therapy (n = 30) were 84.0%, 87.0%, and 66.7% (95% confidence interval: 73.8–94.2%, 77.3–96.7%, and 49.8–83.6%), respectively. Overall, culture‐guided therapy achieved a higher eradication rate than empirical therapy (85.4% vs 66.7%; 95% confidence interval, 0.4% to 37.0%, P = 0.022). Conclusions Culture‐guided therapy with high‐dose PPI achieves a higher eradication rate than empirical therapy with high‐dose PPI in the third‐line treatment of H. pylori infection. The eradication rate of rescue therapy with bismuth plus two susceptible antibiotics is not inferior to that with three susceptible antibiotics.