Triple vs. quadruple therapy for treating Helicobacter pylori infection: a meta-analysis

Aliment Pharmacol Ther. 2003 May 1;17(9):1137-43. doi: 10.1046/j.1365-2036.2003.01566.x.


Background: Triple therapy (proton pump inhibitor, clarithromycin and amoxicillin or an imidazole) is the first-line treatment for Helicobacter pylori infection. However, the effectiveness of triple therapy is decreasing due to the increase in antibiotic resistance. Quadruple therapy (proton pump inhibitor, tetracycline, metronidazole and a bismuth salt) is a very effective regimen even in areas of high prevalence of antibiotic resistance, and may be an alternative first-line treatment.

Aim: To compare triple vs. quadruple therapy for the first-line treatment of H. pylori infection.

Methods: An extensive literature search was performed to identify randomized trials comparing triple vs. quadruple therapy. Selected trials were included in a meta-analysis using Review Manager 4.1.

Results: Four studies met the inclusion criteria. Eradication rates with quadruple therapy were slightly higher in both the intention-to-treat (81% vs. 78%; odds ratio, 0.83; 95% confidence interval, 0.61-1.14) and per protocol (88% vs. 85%; odds ratio, 0.81; 95% confidence interval, 0.55-1.20) analysis, although the differences were not statistically significant. Nor were there significant differences in compliance or adverse effects between the therapies.

Conclusion: Triple and quadruple therapies seem to be roughly equivalent in terms of effectiveness, compliance and side-effects profile when administered as first-line treatment for H. pylori infection.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Amoxicillin / administration & dosage
  • Antacids / administration & dosage
  • Anti-Bacterial Agents / administration & dosage*
  • Bismuth / administration & dosage
  • Clarithromycin / administration & dosage
  • Ditiocarb / administration & dosage
  • Drug Resistance, Bacterial
  • Drug Therapy, Combination / administration & dosage
  • Helicobacter Infections / drug therapy*
  • Helicobacter pylori*
  • Humans
  • Metronidazole / administration & dosage
  • Proton Pump Inhibitors
  • Randomized Controlled Trials as Topic
  • Tetracycline / administration & dosage


  • Antacids
  • Anti-Bacterial Agents
  • Proton Pump Inhibitors
  • Metronidazole
  • Amoxicillin
  • Ditiocarb
  • Tetracycline
  • Clarithromycin
  • Bismuth