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

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, bismuth subsalicylate, tetracycline, and metronidazole, as it has the highest success rate and avoids the potential problem of antibiotic overuse. This recommendation is based on the most recent guidelines, which emphasize the importance of succeeding on the first attempt to avoid retreating and retesting, and reducing cost, anxiety, and negative impacts on other gut microbiota 1. The guidelines suggest that the choice of first-line treatment should be based on previous antibiotic exposure or known local prevalence of resistant organisms. Some key points to consider when treating H pylori infection include:

• The duration of first-line therapies, with 14 days being recommended for all first-line treatments to ensure higher success rates 1
• The use of bismuth quadruple therapy, which is favored in areas of high dual resistance to clarithromycin and metronidazole, and has acceptable success even in strains displaying in vitro metronidazole resistance 1
• The avoidance of levofloxacin as a first-line therapy, unless in specific cases where bismuth is not available and the patient is from an area of high dual resistance and low levofloxacin resistance 1
• The importance of confirming treatment success with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and after stopping PPI for at least 2 weeks. It is also crucial to educate patients on the importance of adherence to the full treatment course, avoiding alcohol during treatment, and being aware of possible side effects such as nausea, metallic taste, and diarrhea.

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.

H. pylori treatment options with amoxicillin include:

• 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 clarithromycin resistance 2

From the Research

H pylori Treatment Options

• The treatment of H pylori infection typically involves a combination of antibiotics and a proton-pump inhibitor (PPI) 3, 4, 5, 6, 7.
• The choice of antibiotics depends on the local prevalence of clarithromycin resistance and the previous use of macrolides 5, 7.
• Quadruple therapies, including bismuth quadruple and concomitant therapies, are recommended as first-line treatments 5, 7.
• A 14-day clarithromycin-containing triple therapy may be suggested in areas with low prevalence of clarithromycin resistance and in patients without previous use of macrolides 7.

Treatment Regimens

• A common treatment regimen consists of a PPI, such as omeprazole, plus two antibiotics, such as amoxicillin and clarithromycin, or amoxicillin and metronidazole 3, 4.
• The regimen may be taken for 7-14 days, with the option to extend treatment to 10 or 14 days to improve eradication rates 3.
• Sequential treatment with amoxicillin for 5 days, followed by clarithromycin and metronidazole for 5 days, has also been shown to be effective 3.

Efficacy and Safety

• The efficacy of H pylori treatment regimens can vary, with eradication rates ranging from 70% to 96% 3, 6.
• Adverse effects are generally mild and may include gastrointestinal disorders and disulfiram-like reactions 3, 4.
• Probiotic supplementation may be used to reduce antibiotic-related adverse events 7.

Resistance and Treatment Failure

• Increasing antibiotic resistance is a significant factor contributing to eradication failure 5.
• Second-line treatments, including levofloxacin-containing triple therapy and bismuth quadruple therapy, may be used in cases of treatment failure 7.
• Tailored therapy based on antibiotic sensitivity testing may be optimal, but has limitations for clinical use 5.