P3450 - Tailored Culture/PCR-Guided Therapy Beats Concomitant Quadruple for H. pylori With 9% Cure Rate and 33% Fewer Adverse Events: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Ashesh Das, MBBS¹, Venkata Dileep Kumar Veldi, MBBS², FNU Sawaira, ³, Shayan Mahapatra, MD⁴, Noorul Hidhaya, MBBS⁵, Ashfaq Sulaiman Arif Abdul Rahuman, MBBS⁶, Anushka Anand. Hanchate, MBBS⁷, Souhardya Baidya, ⁸, Shankar Biswas, MD⁹, Mahafuja Ima, MBBS¹⁰, Shriya D. Tayade, MBBS¹¹, Aashrita G. Divakar, MBBS¹²
1KPC Medical College and Hospital , Kolkata, India, Kolkata, West Bengal, India; 2Gayatri Vidya Parishad Institute of Health care and Medical Technology, Visakhapatnam, Andhra Pradesh, India; 3Khyber Medical University, Mardan, North-West Frontier, Pakistan; 4Aiken Regional Medical Center, Graniteville, SC; 5Stanley Medical College, Chennai, Tamil Nadu, India; 6Madras Medical College, Thiruvananthapuram, Kerala, India; 7Mgm Medical College and Hopsital , Kamothe ,Navi mumbai, Mumbai, Maharashtra, India; 8Institute of Post Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, Haldia, West Bengal, India; 9Ivano-Frankivsk National Medical University, Ukraine, Meerut, Uttar Pradesh, India; 10Uttara adhunik medical college, South Ozone Park, NY; 11RAK Medical and Health Sciences University, New York, NY; 12Manipal university, Bangalore North, Karnataka, India

Introduction: Rising dual clarithromycin- and metronidazole-resistance has pushed empiric concomitant quadruple therapy for Helicobacter pylori to the brink of unacceptable failure rates, forcing gastroenterologists to balance cure against collateral antibiotic exposure. Culture-guided or 23S-rRNA PCR-guided regimens promise precision—prescribing only what each strain requires—yet their true advantage over standard therapy has remained uncertain across heterogeneous populations. To resolve this, we pooled Five Randomized Controlled (RCTs) comparing susceptibility-tailored therapy with 10–14-day concomitant therapy, interrogating both efficacy and safety.

Methods: A systematic search of PubMed, Embase, Scopus, and Cochrane Library identified RCTs comparing Tailored Vs Concomitant Therapy for H pylori eradication through May 2025. Data were analysed using RevMan 4.2.1. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using Mantel-Haenszel methods. Random- or fixed-effects models were applied based on heterogeneity (Higgins’ I²). Statistical significance was set at p < 0.05. Risk of bias was assessed using RoB 2.0.

Results: Five RCTs encompassing 1,552 treatment-naïve adults (tailored = 763, concomitant = 789) met inclusion. Tailored (culture/PCR-guided) therapy produced a significantly higher primary eradication rate than concomitant therapy (RR 1.09, 95 % CI 1.02–1.16; I² = 42 %, p = 0.006). Any adverse event occurred in 21.7 % (163/751) of tailored-treated versus 31.6 % (246/778) of concomitant-treated patients, yielding a 33 % relative risk reduction with tailoring (RR 0.67, 95 % CI 0.47–0.95; I² = 70 %, p = 0.03). Moderate–severe events were infrequent and statistically comparable (RR 0.50, 95 % CI 0.12–2.05; I² = 57 %, p = 0.34).

Discussion: The combined gains in eradication efficacy and tolerability translate into fewer retreatments, endoscopy visits, and antibiotic courses, directly benefiting patients and stewardship efforts. Where resistance profiling is feasible, culture or rapid PCR testing should shift from “optional” to preferred first-line practice, replacing the shotgun quadruple approach. Although upfront logistics require attention, the clinical payoff—higher cure, lower toxicity, and slower resistance accrual—strongly supports upgrading susceptibility-guided therapy in future guidelines for H. pylori management.


Figure: Forest plots of Eradication Rate, Any Adverse Events and Moderate to Severe Adverse Events

Disclosures:
Ashesh Das indicated no relevant financial relationships.
Venkata Dileep Kumar Veldi indicated no relevant financial relationships.
FNU Sawaira indicated no relevant financial relationships.
Shayan Mahapatra indicated no relevant financial relationships.
Noorul Hidhaya indicated no relevant financial relationships.
Ashfaq Sulaiman Arif Abdul Rahuman indicated no relevant financial relationships.
Anushka Hanchate indicated no relevant financial relationships.
Souhardya Baidya indicated no relevant financial relationships.
Shankar Biswas indicated no relevant financial relationships.
Mahafuja Ima indicated no relevant financial relationships.
Shriya Tayade indicated no relevant financial relationships.
Aashrita Divakar indicated no relevant financial relationships.

Ashesh Das, MBBS¹, Venkata Dileep Kumar Veldi, MBBS², FNU Sawaira, ³, Shayan Mahapatra, MD⁴, Noorul Hidhaya, MBBS⁵, Ashfaq Sulaiman Arif Abdul Rahuman, MBBS⁶, Anushka Anand. Hanchate, MBBS⁷, Souhardya Baidya, ⁸, Shankar Biswas, MD⁹, Mahafuja Ima, MBBS¹⁰, Shriya D. Tayade, MBBS¹¹, Aashrita G. Divakar, MBBS¹². P3450 - Tailored Culture/PCR-Guided Therapy Beats Concomitant Quadruple for <i>H. pylori</i> With 9% Cure Rate and 33% Fewer Adverse Events: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.