First-Line Levofloxacin-Based Triple Therapy Versus Standard Bismuth-Based Quadruple Therapy for Helicobacter pylori Eradication in Saudi Arabia: A Retrospective Single-Center Study

Background and Aims: Antibiotic resistance in Saudi Arabia has led to decreased efficacy of conventional triple therapy for Helicobacter pylori (H. pylori) eradication, prompting the development of alternative treatments like levofloxacin-based triple and bismuth-based quadruple therapies. However, comparative data regarding its efficacy are lacking. Therefore, this study's goal was to compare the efficacy of levofloxacin-based triple therapy with that of standard bismuth-based quadruple therapy as first-line regimens. Methods: This retrospective analysis included 197 treatment-naïve adults with H. pylori infection who received levofloxacin-based triple (levofloxacin + amoxicillin + PPI) therapy (n = 81) or standard bismuth-based quadruple (bismuth + tetracycline + metronidazole + PPI) therapy (n = 116). H. pylori eradication was evaluated 4–8 weeks after medication administration using the ¹³C-urea breath test, and variables that could affect the rate of success were examined. Results: There were no differences between groups in terms of age, sex, nationality, or type of proton pump inhibitor (PPI) used. The bismuth-based quadruple therapy group exhibited a markedly superior success rate compared to the levofloxacin-based triple therapy group when the latter was administered for 7 or 10 days (81.03% vs. 6.66%, p < 0.001, and 81.03% vs. 36.1%, p < 0.001, respectively). However, when the levofloxacin-based triple therapy was extended to 14 days, its H. pylori eradication rate became comparable to that of the 10-day bismuth-based quadruple therapy (81.03% vs. 80%, p = 0.898). Eradication rates for both regimens were similar for patients aged ≥ 60, non-Saudi, when using omeprazole and those treated with levofloxacin-based triple therapy for 14 days. Conclusion: Quadruple treatment based on bismuth is superior to triple therapy based on levofloxacin for eradicating H. pylori in Saudi Arabia and should be used as a first-line treatment. However, the 14-day levofloxacin-based triple treatment had an H. pylori eradication rate comparable to that of the 10-day bismuth-based quadruple therapy.