From the Guidelines
The most effective treatment for H. pylori infection is a 14-day course of bismuth quadruple therapy, which includes a proton pump inhibitor (PPI), bismuth subsalicylate, tetracycline, and metronidazole, as it achieves the highest cure rates and minimizes the risk of antibiotic resistance. This approach is supported by the most recent guidelines, which emphasize the importance of optimizing treatment outcomes while reducing antimicrobial resistance 1. The use of bismuth quadruple therapy is particularly recommended in areas with high clarithromycin resistance, as it has been shown to be effective even in the presence of metronidazole resistance 1.
Some key points to consider when treating H. pylori infection include:
- The importance of testing for eradication at least 4 weeks after completing therapy using a urea breath test, stool antigen test, or endoscopic biopsy 1
- The need to avoid alcohol during treatment due to potential interactions with metronidazole
- The potential benefits of using probiotics to reduce antibiotic-associated side effects
- The importance of surveillance and monitoring of treatment outcomes to ensure the continued effectiveness of recommended therapies 1
In terms of specific treatment regimens, the following options may be considered:
- Bismuth quadruple therapy: PPI, bismuth subsalicylate 525mg four times daily, tetracycline 500mg four times daily, and metronidazole 500mg three times daily for 14 days
- Levofloxacin-based triple therapy: PPI, amoxicillin 1g twice daily, and levofloxacin 500mg once daily for 14 days (although this option is not recommended as a first-line treatment due to concerns about antibiotic resistance) 1
From the FDA Drug Label
Adult Patients only Helicobacter pylori Infection and Duodenal Ulcer Disease: Triple therapy for Helicobacter pylori (H. pylori) with clarithromycin and lansoprazole : Amoxicillin, in combination with clarithromycin plus lansoprazole as triple therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) to eradicate H. pylori. Dual therapy for H. pylori with lansoprazole : Amoxicillin, in combination with lansoprazole delayed-release capsules as dual therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) who are either allergic or intolerant to clarithromycin or in whom resistance to clarithromycin is known or suspected.
Treatment of H. pylori can be achieved with amoxicillin in combination with other medications. The recommended treatments are:
- Triple therapy: amoxicillin, clarithromycin, and lansoprazole
- Dual therapy: amoxicillin and lansoprazole, for patients who are allergic or intolerant to clarithromycin, or in cases of known or suspected resistance to clarithromycin 2
From the Research
Treatment Options for H.pylori
- The standard triple therapy for H.pylori eradication, consisting of a proton pump inhibitor, amoxicillin, and clarithromycin, is no longer effective as an empiric choice in most areas due to rising antibiotic resistance 3, 4.
- A 14-day regimen of high-dose proton pump inhibitor triple therapy, including lansoprazole, amoxicillin, and long-acting clarithromycin, has been shown to provide an excellent cure rate of 100% regardless of the CYP2C19 genotype 3.
- Alternative therapy options, such as bismuth quadruple therapy or levofloxacin-based therapies, should be considered in areas with high macrolide resistance rates 4.
- The choice of proton pump inhibitor does not appear to significantly impact the eradication rate of H.pylori 5, 6.
Eradication Rates and Resistance
- The eradication rates of H.pylori using triple therapy have been reported to be around 70-80% in some studies 5, 6.
- Resistance to clarithromycin has been increasing over time, with primary resistance rates rising from 8.7% to 34.5% between 1997 and 2008 7.
- The eradication rate of H.pylori has been shown to decrease significantly over time, from 90.6% to 74.8% between 1997 and 2008, due to increasing clarithromycin resistance 7.