From the Guidelines
The current evidence-based practice treatment for positive Helicobacter pylori infection is a standard triple therapy regimen, consisting of a proton pump inhibitor (PPI), amoxicillin, and clarithromycin, for 14 days, if low clarithromycin resistance is present 1.
First-Line Treatment
The first-line treatment typically consists of:
- A PPI standard dose twice a day
- Amoxicillin 1000 mg twice a day
- Clarithromycin 500 mg twice a day This regimen is recommended as first-line therapy if low clarithromycin resistance is present, based on moderate-quality evidence 1.
Alternative Therapies
Alternatively, a 10-day levofloxacin-amoxicillin triple therapy can be used as second-line therapy if first-line therapy fails, with the following doses:
- PPI standard dose twice a day
- Levofloxacin 500 mg once a day or 250 mg twice a day
- Amoxicillin 1000 mg twice a day
Considerations
It is essential to consider the prevalence of primary resistance in the population when choosing a treatment regimen, as the response to eradication therapy is significantly related to this factor 1.
Recent Guidelines
Recent guidelines recommend abandoning empiric use of clarithromycin, metronidazole, and levofloxacin triple therapies due to increasing antimicrobial resistance, and adopting the principles of antibiotic usage and antimicrobial stewardship 1.
Eradication Confirmation
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.
Importance of Treatment
H. pylori eradication is crucial because the bacterium causes chronic gastritis and is associated with peptic ulcer disease, gastric cancer, and MALT lymphoma. Treatment success has been challenged by increasing antibiotic resistance, making longer treatment durations and quadruple therapy regimens more effective than traditional triple therapy approaches.
From the FDA Drug Label
14.2 H. pylori Eradication in Patients with Duodenal Ulcer Disease Triple Therapy (omeprazole/clarithromycin/amoxicillin) Three U.S., randomized, double-blind clinical studies in patients with H. pylori infection and duodenal ulcer disease (n = 558) compared omeprazole plus clarithromycin plus amoxicillin with clarithromycin plus amoxicillin The dose regimen in the studies was omeprazole 20 mg twice daily plus clarithromycin 500 mg twice daily plus amoxicillin 1 g twice daily for 10 days; or clarithromycin 500 mg twice daily plus amoxicillin 1 g twice daily for 10 days.
The current evidence-based treatment for positive H. pylori is triple therapy consisting of:
- Omeprazole 20 mg twice daily
- Clarithromycin 500 mg twice daily
- Amoxicillin 1 g twice daily for 10 days 2.
This regimen has been shown to be effective in eradicating H. pylori in patients with duodenal ulcer disease.
From the Research
Current EBP Treatment for Positive H. Pylori
- The current evidence-based practice (EBP) treatment for positive H. Pylori involves various regimens, including triple and quadruple therapies 3, 4, 5, 6, 7.
- A study from 1998 found that a quadruple therapy regimen consisting of amoxicillin, metronidazole, omeprazole, and clarithromycin was effective in eradicating H. Pylori, with an eradication rate of 96% 3.
- Another study from 2010 compared the efficacy of two quadruple therapy regimens, one containing azithromycin, ofloxacin, bismuth, and omeprazole, and the other containing amoxicillin, clarithromycin, bismuth, and omeprazole, and found that the first regimen had a higher eradication rate of 77.3% compared to 64.5% for the second regimen 4.
- A 2015 study found that a modified bismuth quadruple therapy regimen consisting of lansoprazole, amoxicillin, bismuth, and metronidazole or clarithromycin was effective in eradicating H. Pylori, with an eradication rate of 96.9% for the metronidazole group and 94.9% for the clarithromycin group 5.
- A 2001 study compared the efficacy of two retreatment regimens, one containing lansoprazole, amoxicillin, and clarithromycin, and the other containing lansoprazole, bismuth, metronidazole, and tetracycline, and found that both regimens were effective in retreating patients who failed initial H. Pylori therapy, with an eradication rate of 82% for the first regimen and 80% for the second regimen 6.
- A 2016 systematic review and meta-analysis found that triple therapy combining a proton-pump inhibitor, amoxicillin, and metronidazole was less efficacious than clarithromycin-including triple therapies, but its efficacy was similar to that of PAC when drugs were administered for 14 days 7.
Treatment Options
- Triple therapy regimens, such as PPI, amoxicillin, and metronidazole (PAM) or PPI, metronidazole, and clarithromycin (PMC) 7.
- Quadruple therapy regimens, such as amoxicillin, metronidazole, omeprazole, and clarithromycin, or azithromycin, ofloxacin, bismuth, and omeprazole 3, 4.
- Modified bismuth quadruple therapy regimens, such as lansoprazole, amoxicillin, bismuth, and metronidazole or clarithromycin 5.