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 is favored due to its high success rate even in areas with high dual resistance to clarithromycin and metronidazole. This approach is recommended by recent guidelines, including the Toronto Consensus, which concludes that 14 days of treatment is more effective than shorter durations 1. The bismuth quadruple therapy typically consists of a proton pump inhibitor (PPI), bismuth subsalicylate, tetracycline, and metronidazole.

Some key points to consider when treating H pylori infection include:

• The choice of first-line treatment should be based on previous antibiotic exposure or local prevalence of resistant organisms 1
• Concomitant therapy is an alternative option for patients from areas with high clarithromycin resistance where bismuth is not available 1
• Levofloxacin is not considered a first-line therapy, but may be considered in patients from areas with high dual resistance and low levofloxacin resistance 1
• The duration of first-line therapies should be 14 days, unless 10 days has been proven locally to be as effective for quadruple therapies 1

It is essential to note that treatment success rates have been declining due to increasing antibiotic resistance, which is why longer treatment durations and alternative regimens may be necessary 1. Confirmation of eradication should be performed at least 4 weeks after completing therapy using either a urea breath test, stool antigen test, or endoscopic biopsy. Patients should avoid taking PPIs for 2 weeks and antibiotics for 4 weeks before testing for eradication.

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, 4.
• The choice of antibiotics depends on the local prevalence of clarithromycin resistance and the previous use of macrolides 5, 6.
• Quadruple therapies, including bismuth quadruple and concomitant therapies, are recommended as first-line treatments 5, 6.
• 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 6.

Treatment Regimens

• 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.
• Combination therapy with PPI + amoxicillin + clarithromycin + metronidazole for 5 days can eradicate H. pylori in about 90% of cases 3.
• Sequential treatment with amoxicillin for 5 days, followed by clarithromycin + metronidazole for 5 days, has similar efficacy and adverse effects to simultaneous treatment 3.
• A 5-day quadruple therapy with omeprazole, metronidazole, clarithromycin, and amoxicillin is an effective and safe regimen for H. pylori eradication 7.

Second-Line Treatments

• Levofloxacin-containing triple therapy and bismuth quadruple therapy are recommended as second-line treatments 6.
• Probiotic supplementation may be used to reduce antibiotic-related adverse events 6.

Adverse Effects

• The adverse effects of H. pylori treatment regimens are generally mild and include gastrointestinal disorders and the disulfiram-like reaction of metronidazole 3, 4.
• Bismuth can cause encephalopathy and should only be used in special cases 3.