According to a real-world clinical study published in "Journal of Gastroenterology and Hepatology", culture-guided therapy combined with high-dose proton pump inhibitor (PPI) had a greater eradication rate than empirical therapy when used as the third-line treatment for Helicobacter pylori (H. pylori) infection.

Researchers sought to assess the effectiveness of culture-based therapy and empirical therapy with PPI for H. pylori management. H. pylori-infected patients who had experienced a minimum of 2 unsuccessful eradication attempts were given anti-H. pylori treatment (as per outcomes of antimicrobial sensitivity tests) along with high-dose Rabeprazole and/or Bismuth.

They were divided into three groups: (A) Those with positive culture results with one to two susceptible antibiotics received culture-guided Bismuth-containing therapy, (B) Those with positive culture results with three or more susceptible antibiotics received culture-guided non-Bismuth quadruple therapy, and (C) Those with negative culture results received therapy guided by high-dose Rabeprazole plus Amoxicillin, Levofloxacin and Tetracycline. 

At week eight, a post-treatment evaluation was carried out. Overall, 126 patients were enrolled. The eradication rates of empirical therapy (n = 30), culture-guided Bismuth-containing therapy (n = 46), and culture-guided non-Bismuth quadruple treatment (n = 50) are depicted in Table 1:

Overall, culture-guided treatment outperformed empirical therapy in terms of eradication rate (85.4% vs. 66.7%).  In the third-line therapy for H. pylori infection, culture-guided treatment with high-dose PPI had a greater rate of elimination than empirical treatment with high-dose PPI. When compared to rescue therapy using three susceptible antibiotics, rescue therapy using Bismuth and two susceptible antibiotics is not inferior.