Empiric H. pylori therapy—10-day concomitant, bismuth quadruple or 14-day triple therapy: none is best
Liou and colleagues recently reported the results of a very large randomized comparative trial of three different H. pylori therapies: 10-day concomitant, 10-day bismuth quadruple therapy, and 14-day triple therapy (1). The technical aspects of the study were truly state-of-the-art in relation to the design, execution, and data collection. Essentially all that one would like to know about the population and the variables that might have influenced outcome are presented clearly. However, planning and completing a clinical trial takes many years and investigators always risk providing answers to the questions asked may no longer be considered important. During the time the study was in progress the concepts of H. pylori treatment made a transition from a being investigated as other gastrointestinal diseases (e.g., constipation) to becoming recognized as an infectious disease (2-4). All infectious disease therapies are whenever possible susceptibility-based. Ineffective therapies are essentially never compared to state of the art therapies to prove superiority rather comparisons are designed as non-inferiority studies where all regimens provide excellent cure rates (5-7).