What is the treatment for Helicobacter pylori (H. pylori) infection?

From the Guidelines

The standard first-line therapy for H. pylori infection is triple therapy, which includes a proton pump inhibitor (PPI), amoxicillin, and clarithromycin, and should be taken for 14 days. This recommendation is based on the most recent and highest quality study available 1. The suggested doses are:

• PPI standard dose twice a day
• Clarithromycin 500 mg twice a day
• Amoxicillin 1000 mg twice a day. In cases where clarithromycin resistance is high, sequential therapy with four drugs (amoxicillin, clarithromycin, metronidazole, and PPI) can be considered 1. If first-line therapy fails, a 10-day levofloxacin-amoxicillin triple therapy is recommended as second-line therapy 1. It's essential to complete the entire course of medication and avoid alcohol during treatment, especially when taking metronidazole.

The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community 1. Some regions may recommend quadruple therapy as first-line treatment due to increasing antibiotic resistance 1. However, the standard triple therapy remains the most widely recommended first-line treatment.

Key points to consider when treating H. pylori infection include:

• Completing the entire course of medication, even if symptoms improve before finishing
• Avoiding alcohol during treatment, especially when taking metronidazole
• Testing for eradication after treatment, typically using a urea breath test, stool antigen test, or endoscopy with biopsy at least 4 weeks after completing antibiotics and 2 weeks after stopping PPI therapy
• Considering the prevalence of resistant strains in the community when choosing a treatment regimen.

Overall, the goal of treatment is to eradicate H. pylori infection and prevent complications such as peptic ulcers, gastritis, and gastric cancer. The most effective treatment regimen is the one that is completed in full and leads to successful eradication of the infection.

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.

The treatment for H. pylori infection is:

• Triple therapy: Amoxicillin in combination with clarithromycin and lansoprazole.
• Dual therapy: Amoxicillin in combination with lansoprazole, for patients who are allergic or intolerant to clarithromycin or have known or suspected resistance to clarithromycin 2.

From the Research

Treatment Options for H. pylori

• The treatment for H. pylori typically involves a combination of antibiotics and acid suppressors, such as proton pump inhibitors (PPIs) 3, 4, 5, 6, 7.
• A study from 2004 found that a 14-day regimen of pantoprazole or lansoprazole, amoxicillin, and clarithromycin achieved an eradication rate of 70% and 69.2%, respectively 3.
• Another study from 2020 recommended the use of bismuth quadruple therapy or levofloxacin-based therapy as alternative options for areas with high macrolide resistance rates 4.
• A 2013 study found that a 14-day regimen of high-dose PPI, amoxicillin, and long-acting clarithromycin achieved an eradication rate of 100% in areas with low clarithromycin resistance 5.
• Older studies from 1996 and 1998 found that triple therapy regimens, such as omeprazole, clarithromycin, and amoxicillin, or quadruple therapy regimens, such as amoxicillin, metronidazole, omeprazole, and clarithromycin, were effective in eradicating H. pylori 6, 7.

Eradication Rates

• The eradication rates for H. pylori treatment vary depending on the regimen and duration of treatment, with rates ranging from 62.2% to 100% 3, 5, 6, 7.
• A study from 1996 found that a 2-week regimen of omeprazole, clarithromycin, and amoxicillin achieved an eradication rate of 95.7% 6.
• Another study from 1998 found that a 5-day quadruple therapy regimen achieved an eradication rate of 96% 7.

Side Effects and Resistance

• The frequency of side effects, such as metallic taste, was higher in some treatment regimens, but most patients did not discontinue treatment due to side effects 3, 6.
• The development of antibiotic resistance, particularly to macrolides, is a concern in H. pylori treatment, and alternative regimens may be necessary in areas with high resistance rates 4.