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

From the Guidelines

The most effective treatment for H pylori infection is 14-day bismuth quadruple therapy, which is recommended as first-line therapy when susceptibility testing or regional data are not available or for a non-invasive test. This approach is supported by recent guidelines that prioritize quadruple therapies for initial treatment due to increasing antibiotic resistance 1. The bismuth quadruple therapy regimen typically includes a proton pump inhibitor (PPI), bismuth subsalicylate, tetracycline, and metronidazole, and has been shown to have acceptable success even in strains displaying in vitro metronidazole resistance 1.

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

• The importance of completing the full course of antibiotics, even if symptoms improve, to ensure successful eradication of the infection
• The need to avoid alcohol during treatment, especially with metronidazole, due to potential side effects
• The potential for side effects such as diarrhea, nausea, and metallic taste, and the importance of advising patients to be aware of these possibilities
• The recommendation to confirm treatment success with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and while off PPI therapy for at least 2 weeks

In areas with high clarithromycin resistance or for patients with penicillin allergy, bismuth quadruple therapy is a suitable alternative to triple therapy regimens 1. The duration of first-line therapies is also an important consideration, with 14 days being the recommended duration for most treatments due to higher success rates compared to shorter durations 1. Overall, the goal of treatment is to eradicate the H pylori infection and prevent associated complications such as chronic gastritis, peptic ulcer disease, and gastric cancer.

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 in cases of known or suspected resistance to clarithromycin 2

From the Research

Treatment Options for H. pylori Infection

• The standard triple therapy, which includes a proton pump inhibitor (PPI), clarithromycin, and amoxicillin, is a commonly used treatment for H. pylori infection 3.
• However, the efficacy of this treatment has been declining due to increasing antimicrobial resistance, and its performance is now considered unacceptable in some cases 4.
• Bismuth quadruple therapy is recommended as the best initial empiric treatment for H. pylori infection, especially when clarithromycin resistance is suspected 4.
• Concomitant, sequential, and hybrid therapies are also effective bismuth-free quadruple options, but their use depends on the level of dual clarithromycin-metronidazole resistance 4.

Duration of Treatment

• The optimal duration of treatment for H. pylori infection is still a topic of debate, with recommendations ranging from 7 to 14 days 5.
• Studies have shown that increasing the duration of PPI-based triple therapy can increase the eradication rate of H. pylori, with 14 days being the most effective duration 5.
• However, the benefit of increasing the duration of therapy for other regimens, such as PCN therapy, is still unclear and requires further study 5.

Alternative Treatment Options

• Levofloxacin-, rifabutin-, furazolidone-, and sitafloxacin-containing regimens are useful alternatives for H. pylori eradication, particularly as salvage options 4.
• High-dose dual therapy (PPI plus amoxicillin) and vonoprazan, a more potent acid inhibitor, are promising alternatives that could decrease the misuse of antibiotics 4.
• The addition of certain probiotics may also increase the performance of H. pylori eradication regimens and improve tolerability 4.

Regional Variations in Treatment Efficacy

• The efficacy of standard triple therapy has been shown to vary by region, with higher eradication rates observed in Asian populations compared to European populations 3.
• This variation may be due to differences in antibiotic resistance patterns, patient demographics, and other factors, highlighting the need for region-specific treatment guidelines 3.