What are the eradication options for Helicobacter pylori (H. pylori) infection?

From the Guidelines

The most effective eradication option for Helicobacter pylori is concomitant non-bismuth quadruple therapy (PAMC) consisting of a proton pump inhibitor (PPI), amoxicillin, metronidazole, and clarithromycin for 14 days, as recommended by all guidelines 1.

Eradication Options

The treatment of Helicobacter pylori infection requires a combination of medications, typically including antibiotics and acid-suppressing drugs. The available eradication options include:

• Concomitant non-bismuth quadruple therapy (PAMC)
• Bismuth quadruple therapy (PBMT)
• PPI triple therapy (PAC, PMC)
• Levofloxacin triple therapy (PAL)
• Sequential non-bismuth quadruple therapy
• Hybrid non-bismuth quadruple therapy
• High-dose dual therapy
• Rifabutin-containing therapy (PAR)

First-Line Treatment

The first-line treatment for Helicobacter pylori infection is concomitant non-bismuth quadruple therapy (PAMC) or bismuth quadruple therapy (PBMT), as both are recommended by all guidelines 1.

Treatment Duration

The preferred duration of first-line therapy is 14 days, as it has been shown to be superior to 10-day regimens 1.

Penicillin Allergy

In patients with true penicillin allergy, bismuth quadruple therapy or clarithromycin-based triple therapy with metronidazole can be used as alternative options 1.

Rescue Therapy

If first-line therapy fails, levofloxacin-based triple therapy or other rescue options can be considered, as recommended by the guidelines 1.

Importance of Eradication

Eradication of Helicobacter pylori is important because the bacterium causes chronic gastritis, peptic ulcers, and is associated with gastric cancer. Treatment success depends on patient adherence, antibiotic resistance patterns, and proper acid suppression during treatment.

Confirmation of Eradication

Eradication should be confirmed with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and after PPI discontinuation for at least 2 weeks.

From the FDA Drug Label

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. The combination of omeprazole plus clarithromycin plus amoxicillin was effective in eradicating H. pylori.

Eradication options for Helicobacter pylori include:

• Triple therapy: omeprazole, clarithromycin, and amoxicillin
• Dual therapy: omeprazole and clarithromycin The most effective eradication option is the triple therapy regimen, which includes omeprazole, clarithromycin, and amoxicillin 2.

From the Research

Eradication Options for Helicobacter

• First-line treatment: The recommended first-line treatment in published guidelines in Europe and North America is proton pump inhibitor combined with amoxicillin and clarithromycin, as stated in 3.
• Second-line treatment: Bismuth-based quadruple therapies and levofloxacin-based regimes have been shown to be effective second-line regimens, according to 3.
• Third-line options: Regimens based on rifabutin or furazolidone are considered third-line options, but susceptibility testing is the most rational option, as mentioned in 3.
• Emerging treatment regimens: Modified bismuth-containing quadruple regimen, high-dose dual therapy, and vonoprazan-containing regimens have been proposed as useful modified regimens, with acceptable eradication rates and safety, as discussed in 4.
• Quadruple therapy: A new, short quadruple therapy for Helicobacter pylori eradication, including amoxicillin, metronidazole, omeprazole, and clarithromycin, has been shown to be effective and safe, as reported in 5.
• Levofloxacin-based triple therapy: This regimen has been found to be effective for first-line Helicobacter pylori eradication, with eradication rates of 86.2% and 93.6% for 7-day and 10-day therapy, respectively, as stated in 6.
• Proton pump inhibitor - amoxicillin - clarithromycin triple therapy: This regimen has been improved with a high-dose proton pump inhibitor and long-acting clarithromycin, achieving an excellent cure rate of 100% regardless of the CYP2C19 genotype, as mentioned in 7.

Treatment Regimens

• Bismuth-containing quadruple therapy: This regimen is considered a second-line option and has its own limitations, such as complex drug administration, as discussed in 4.
• Concomitant therapy: This regimen is also considered a radical treatment regimen for Helicobacter pylori, as mentioned in 4.
• Sequential therapy: This regimen is promising but needs further study and validation outside of Italy, as stated in 3.

Factors Affecting Eradication Rates

• Antibiotic resistance: The increasing resistance to clarithromycin and metronidazole has led to a decline in eradication rates, as mentioned in 4 and 6.
• Compliance: Good compliance with therapy is essential to achieve high eradication rates, as stated in 3.
• Drug susceptibility testing: This testing is not widely used but is considered the most rational option for third-line treatment, as mentioned in 3.