This study compared a 1-week triple regimen plus bismuth (PBMA: proton pump inhibitor [PPI], bismuth, metronidazole, amoxicillin) with the conventional 2-week bismuth-based quadruple regimen (PBMT: PPI, bismuth, metronidazole, tetracycline), using propensity score-matched cohorts. Notably, the eradication rates were comparable between the two groups in both intention-to-treat and per-protocol analyses, with no significant differences in adverse events or medication compliance. Although this was a retrospective study, the findings suggest that a shorter regimen may achieve comparable clinical outcomes.

The 1-week PBMA regimen offers several potential advantages. Reducing antibiotic exposure and treatment duration may improve patient compliance and minimize adverse events. Amoxicillin, which is generally better tolerated than tetracycline, may be more suitable for elderly patients or those with underlying health conditions. In addition, shorter regimens may help decrease selective pressure on gut microbiota and reduce overall healthcare costs. A key strength of this study lies in its focus on genetically confirmed clarithromycin-resistant strains, supporting a more personalized approach to eradication therapy. This study offers a practical approach to balancing efficacy, patient adherence, and reduced antibiotic use.

While the findings are clinically meaningful, several limitations should be considered. The retrospective design, relatively small sample size, and single-center nature may limit the generalizability of the results. Previous Korean retrospective studies have shown that 7-day PBMT therapy resulted in significantly lower eradication rates compared to 10- or 14-day regimens [2]. Although the antibiotic composition differs in the present study, whether a 7-day treatment is sufficient remains uncertain and warrants further investigation in larger, prospective trials.

To further improve eradication outcomes in clarithromycin-resistant cases, an emerging strategy is the use of potassium-competitive acid blockers (PCABs), which provide more potent and sustained acid suppression than conventional PPIs. Vonoprazan-based regimens have demonstrated superior eradication rates compared to PPI-based therapies, particularly in clarithromycin-resistant infections, likely due to improved intragastric pH control that enhances antibiotic activity [3]. This is especially relevant for regimens including amoxicillin, which is more pH-dependent than tetracycline; thus, the enhanced acid suppression provided by PCABs may further optimize the efficacy of amoxicillin-containing therapies. Incorporating PCABs into simplified regimens such as the 1-week PBMA may therefore improve both clinical outcomes and patient adherence, especially as these agents become more widely available in Korea.

Overall, the 1-week PBMA regimen appears to be a feasible and patient-centered alternative for clarithromycin-resistant H. pylori infection. While further prospective studies are needed, this approach aligns with the broader goal of optimizing efficacy, improving adherence, and minimizing unnecessary antibiotic use in the era of rising resistance.