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

From the Guidelines

The first-line treatment for H. pylori infection is standard triple therapy, consisting of amoxicillin, clarithromycin, and a proton pump inhibitor (PPI), which is recommended for 14 days if low clarithromycin resistance is present 1. This treatment approach is based on moderate-quality evidence and is widely endorsed by Western scientific societies and regulatory authorities.

Key Components of Treatment

• PPI standard dose twice a day
• Clarithromycin 500 mg twice a day
• Amoxicillin 1000 mg twice a day The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community, as the response to eradication therapy is significantly related to the prevalence of primary resistance in the population 1.

Alternative Treatment Options

If clarithromycin high resistance is detected, sequential therapy with four drugs (amoxicillin, clarithromycin, metronidazole, and PPI) may be considered, with the recommended doses being:

• PPI standard dose twice a day
• Amoxicillin 1000 mg twice a day
• Clarithromycin 500 mg twice a day
• Metronidazole 500 mg twice a day If first-line therapy fails, a second-line therapy consisting of a 10-day levofloxacin-amoxicillin triple therapy may be used, with the suggested doses being:
• PPI standard dose twice a day
• Levofloxacin 500 mg once a day or 250 twice a day
• Amoxicillin 1000 mg twice a day It is essential to note that the treatment regimen should be chosen based on the prevalence of resistant strains in the community and that patients should be tested to confirm eradication after completing treatment 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.

The treatment for H. pylori infection includes:

• 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 medications, including proton pump inhibitors, antibiotics, and sometimes bismuth-based therapies 3, 4.
• Studies have shown that the efficacy of triple therapy containing clarithromycin, a commonly used antibiotic, is declining due to increasing antibiotic resistance of H Pylori 4, 5.
• Alternative treatment regimens, such as bismuth quadruple therapy and non-bismuth quadruple therapies, have been proposed as first-line options in regions with high clarithromycin resistance 4.

Eradication Rates and Treatment Duration

• A study comparing the efficacy of two different triple therapy regimens found that the regimen consisting of omeprazole, metronidazole, and amoxicillin had a higher eradication rate (96.4%) compared to the regimen consisting of lansoprazole, clarithromycin, and amoxicillin (74.5%) 3.
• Another study found that a 14-day regimen of high-dose proton pump inhibitor, amoxicillin, and long-acting clarithromycin achieved a 100% eradication rate, regardless of the patient's CYP2C19 genotype 6.
• The importance of clarithromycin dose in the management of H Pylori infection has also been studied, with results suggesting that a dose of 500 mg twice daily is more effective than 250 mg twice daily 7.

Resistance and Treatment Outcomes

• The rise in clarithromycin resistance has been linked to a decline in eradication rates, with one study finding that primary resistance to clarithromycin increased from 8.7% to 34.5% over a 12-year period, resulting in a significant decrease in eradication rates 5.
• The choice of proton pump inhibitor may also impact treatment outcomes, with some studies suggesting that rabeprazole may be more effective than omeprazole or lansoprazole in achieving eradication 5.