The Re-Emergence of Bismuth-Based Therapies in the Treatment of Helicobacter pylori

Helicobacter pylori remains one of the most prevalent chronic bacterial infections worldwide and is a causative agent in peptic ulcer disease and gastric cancer. The management of H. pylori has evolved substantially since the discovery of the organism in the 1980s, largely in response to increasing antibiotic resistance and declining efficacy of conventional triple therapy. Bismuth compounds, historically used in the treatment of dyspeptic symptoms and peptic ulcer disease, have re-emerged as a cornerstone of eradication therapy due to their unique antimicrobial and mucosal protective properties. This review outlines the historical evolution of bismuth-based therapies, examines the pharmacological formulations and mechanisms of action of bismuth compounds and evaluates the contemporary evidence supporting bismuth-based quadruple therapy (BQT). Current international guidelines increasingly recommend BQT as first-line treatment, particularly in regions with high clarithromycin resistance. Evidence from recent clinical trials and meta-analyses demonstrates consistently high eradications rates with BQT, including effectiveness in resistant infections. We also discuss safety, tolerability, antibiotic resistance considerations and emerging future directions. Overall, current evidence supports BQT as a highly effective and increasingly important strategy in modern H. pylori management.