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 bismuth quadruple therapy, which includes a proton pump inhibitor (PPI), two antibiotics, and bismuth subsalicylate, as it has been shown to have the highest success rate in eradicating the infection, especially in areas with high antibiotic resistance 1. The treatment approach for H. pylori infection has evolved over the years, with a focus on personalized therapy based on antibiotic susceptibility profiles and local resistance patterns. The standard first-line treatment options include:

• Bismuth quadruple therapy, which consists of a PPI, two antibiotics (such as amoxicillin and metronidazole), and bismuth subsalicylate, for 14 days 1
• Concomitant therapy, which includes a PPI, two antibiotics (such as amoxicillin and clarithromycin), and a third antibiotic (such as metronidazole), for 14 days 1
• Sequential therapy, which involves a PPI and two antibiotics (such as amoxicillin and clarithromycin) for 5-7 days, followed by a different combination of antibiotics (such as metronidazole and tinidazole) for an additional 5-7 days 1 It is essential to note that the choice of treatment regimen should be based on the patient's previous antibiotic exposure, local resistance patterns, and the presence of any allergies or intolerances. In cases where triple therapy fails, quadruple therapy is recommended as a second-line option 1. During treatment, patients should be advised to:
• Avoid alcohol due to potential interactions with metronidazole
• Take probiotics to reduce antibiotic side effects
• Complete the full course of medication, even if symptoms improve
• Return for follow-up testing, such as a urea breath test, stool antigen test, or endoscopy, at least 4 weeks after completing therapy and after stopping PPI medications for at least 2 weeks 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 is:

• Triple therapy: Amoxicillin in combination with clarithromycin and lansoprazole
• Dual therapy: Amoxicillin in combination with lansoprazole (for patients allergic or intolerant to clarithromycin or with known/suspected resistance to clarithromycin) 2

From the Research

Treatment Options for H. pylori

The treatment for H. pylori infection typically involves a combination of antibiotics and acid suppressors. Some of the treatment options include:

• Proton pump inhibitor (PPI)-based triple therapy with clarithromycin and amoxicillin 3, 4, 5
• PPI-tetracycline-metronidazole regimen (PTM) as an alternative therapy 3
• Bismuth quadruple therapy 6
• Levofloxacin-based or alternative macrolide-containing therapies 6
• Amoxicillin/metronidazole/omeprazole/clarithromycin quadruple therapy 7

Eradication Rates

The eradication rates of H. pylori infection vary depending on the treatment regimen and duration. Some of the reported eradication rates include:

• 82.8% to 92.3% with PTM regimen 3
• 74.3% to 89.7% with PPI-AMPC-MNZ regimen 3
• 96% to 91% with amoxicillin/metronidazole/omeprazole/clarithromycin quadruple therapy 7
• 89.6% to 95.7% with omeprazole, clarithromycin, and amoxicillin triple therapy 5
• 100% with 14-day high-dose PPI and long-acting clarithromycin triple therapy 4

Treatment Duration and Side Effects

The treatment duration for H. pylori infection can range from 5 to 14 days, depending on the regimen. Some of the reported side effects include:

• Metallic taste with omeprazole, clarithromycin, and amoxicillin triple therapy 5
• No severe adverse effects with PTM regimen 3
• Fewer side effects with quadruple therapy compared to triple therapy 7