Superior Efficacy of Bismuth-Containing Rifabutin Quadruple Therapy over Rifabutin Triple Therapy as Salvage Treatment

Helicobacter pylori is a pathogen that causes chronic gastritis and peptic ulcer diseases and is a carcinogen responsible for the development of malignancies, including gastric cancer. In the current era of high antimicrobial resistance, rifabutin-based triple therapy is recommended as a salvage therapy. Bismuth has not only a strong bacteriostatic effect but also a synergic effect when combined with antibiotics. Our study aimed to compare and evaluate the eradication rates between rifabutin-based triple therapy and rifabutin with bismuth-containing quadruple therapy as salvage treatments. In this single-center study, patients who received rifabutin-based triple therapy and rifabutin with bismuth-containing quadruple therapy after failure of conventional therapy, including first- and second-line treatment, between January 2016 and July 2024, were retrospectively investigated. A total of 53 patients who received rifabutin-based triple therapy and 50 who received bismuth-containing quadruple therapy were included. In the rifabutin-based triple therapy group, eradication was achieved in 32 out of 53 patients (60.4%; 95% confidence interval [CI], 46.8% to 74.0%). In the bismuth-containing quadruple therapy group, eradication was achieved in 40 out of 50 patients (80.0%; 95% CI, 68.5% to 91.5%), demonstrating significant therapeutic benefit (p=0.030). Adverse events, including nausea, epigastric discomfort, and lethargy, were significantly more frequent in the bismuth-containing quadruple therapy group (p=0.007), but they were mild and tolerable enough not to affect compliance (p=0.329). Rifabutin with bismuth-containing quadruple regimen as a salvage treatment achieved significantly superior eradication efficacy over the rifabutin-based triple regimen. Further multicenter prospective studies are needed to provide additional supporting evidence.