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 avoids the potential problem of antibiotic overuse and has acceptable success even in strains displaying in vitro metronidazole resistance. This approach is recommended by recent guidelines, including the Toronto Consensus and the Maastricht V/Florence Consensus, as stated in the 2019 study published in Gastroenterology 1. The guidelines agree that the best approach is to succeed on the first attempt, thus avoiding retreating and retesting, and reducing cost, anxiety, and negative impacts on other gut microbiota. Some key points to consider when treating H pylori infection include:

• The importance of choosing a treatment regimen based on previous antibiotic exposure or known local prevalence of resistant organisms
• The use of concomitant therapy in areas of high clarithromycin resistance where bismuth is not available
• The recommendation to avoid levofloxacin as a first-line therapy, except in specific cases where bismuth is not available and there is low levofloxacin resistance
• The duration of treatment, with 14 days being the recommended duration for most first-line treatments, as supported by the Toronto Consensus and the Maastricht V/Florence Consensus 1. It is essential to complete the entire course of treatment, even if symptoms improve before completion, and to confirm eradication at least 4 weeks after therapy using a urea breath test, stool antigen test, or endoscopic biopsy.

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 standard treatment for H pylori infection typically consists of a combination of antibiotics and a proton-pump inhibitor (PPI) 3.
• A 7-day course of PPI + clarithromycin + amoxicillin is effective in about 70% of cases, but the efficacy can be improved by prolonging the treatment to 10 or 14 days 3.
• Quadruple therapy regimens, such as PPI + amoxicillin + clarithromycin + metronidazole, have been shown to be effective in eradicating H pylori in about 90% of cases 3, 4.

Antibiotic Resistance and Treatment

• The increase in antibiotic resistance, particularly to clarithromycin, has undermined the efficacy of standard triple therapy 5.
• The choice of H pylori eradication regimen should be based on the local prevalence of clarithromycin resistance and the previous use of macrolides 5.
• Second-line treatments, such as levofloxacin-containing triple therapy and bismuth quadruple therapy, are recommended for patients who have failed first-line treatment 5, 6.

Treatment Duration and Efficacy

• A 5-day quadruple therapy regimen has been shown to be effective and safe for H pylori eradication 4.
• Prolonging treatment to 10 or 14 days can improve the rate of H pylori eradication by 5% to 10% 3.
• A 2-week treatment with ofloxacin, azithromycin, omeprazole, and bismuth has been shown to be an effective and safe regimen for H pylori eradication as second-line therapy 6.

Side Effects and Tolerability

• The adverse effects of H pylori treatment regimens are generally mild and consist of gastrointestinal disorders and the disulfiram-like reaction of metronidazole 3.
• Probiotic supplementation can be used to reduce antibiotic-related adverse events 5.
• The frequency of side effects can vary depending on the treatment regimen, with some regimens being better tolerated than others 7.