Eradication rates of Helicobacter pylori regimens and predictors of treatment failure: A multicenter real-world study in Saudi Arabia

Background: The increasing prevalence of Helicobacter pylori resistance to clarithromycin and other antibiotics has led to a decline in eradication rates globally. Limited multicenter data from Saudi Arabia exist regarding the comparative effectiveness of various eradication regimens and predictors of treatment failure. This study aimed to evaluate eradication outcomes across different therapeutic lines and identify predictors of eradication failure in a real-world Saudi population. Methods: A retrospective multicenter cohort study was conducted across several tertiary hospitals in Saudi Arabia, from January 2020 to December 2024. Adult patients with confirmed H. pylori infection who received first-line or subsequent eradication therapy were included. Data were collected from electronic medical records, including demographic characteristics, comorbidities, diagnostic methods, treatment regimens, and therapy outcomes. Eradication success was confirmed by urea breath, stool antigen testing, or histopathology, at least four weeks post-therapy. Multivariate logistic regression was used to identify independent predictors of eradication failure. Results: A total of 690 patients were included (61.0% female; mean age 41 ± 13 years). Concomitant quadruple therapy was the most frequently prescribed regimen (49.0%), followed by standard triple therapy (25.9%). Eradication rates were significantly higher for concomitant (90.2%), levofloxacin-based regimens (87.8%) compared with standard triple therapy (73.7%; P < 0.001). There was no treatment failure among the 28 patients who received bismuth-based therapy, resulting in a 100% eradication rate. Univariate analysis suggested cardiovascular disease as a potential predictor of treatment failure (P = 0.03), but no independent predictors were identified after multivariate adjustment. No demographic or medication-related variables significantly influenced eradication outcomes. Conclusion: In this large, real-world Saudi cohort, concomitant and levofloxacin-based regimens achieved excellent H. pylori eradication rates, while bismuth-based therapy is effective; the reported eradication rate of 100% is most likely inflated, given the small number of patients who received this regimen. In contrast, standard triple therapy showed suboptimal efficacy, likely due to clarithromycin resistance. The findings support replacing triple therapy with quadruple bismuth-containing or non-bismuth-based therapies, or levofloxacin-containing regimens, as first-line therapy, and highlight the need for local antimicrobial resistance surveillance to guide treatment strategies.