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

From the Guidelines

H. pylori treatment should typically involve a 14-day course of bismuth quadruple therapy or concomitant therapy, as these regimens have been shown to be effective in areas with high clarithromycin resistance, as recommended by the most recent guidelines 1. The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community, with bismuth quadruple therapy being favored in areas with high dual resistance to clarithromycin and metronidazole 1. Some key points to consider when treating H. pylori include:

• The use of a proton pump inhibitor (PPI) to suppress acid production and enhance antibiotic effectiveness
• The selection of antibiotics based on the patient's allergy history and the local prevalence of resistant strains
• The duration of treatment, which is typically 14 days for first-line therapies 1
• The importance of confirming treatment success with a urea breath test, stool antigen test, or endoscopy at least 4 weeks after completing therapy and while off PPI medications for at least 2 weeks 1 In areas with low clarithromycin resistance, standard triple therapy with a PPI, amoxicillin, and clarithromycin may be used as a first-line treatment, but bismuth quadruple therapy or concomitant therapy should be considered in areas with high resistance 1. It's also important to note that the prevalence of H. pylori resistance to clarithromycin is highly variable between countries or regions, and the choice of treatment regimen should be based on the local epidemiology of antibiotic resistance 1. Overall, the goal of H. pylori treatment is to eradicate the infection and prevent the development of complications such as peptic ulcers and gastric cancer, and the choice of treatment regimen should be guided by the most recent and highest-quality evidence available 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.

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.
• The standard empirical antibiotic regimen for H. pylori infection in adults with gastric or duodenal ulcer consists of three antibiotics: amoxicillin, clarithromycin, and metronidazole, plus a PPI such as omeprazole 3.
• A 7-day course of PPI + clarithromycin + amoxicillin is effective in only about 70% of cases due to increasing H. pylori resistance to clarithromycin 3.
• Prolonging treatment with a PPI + amoxicillin + clarithromycin or a PPI + amoxicillin + metronidazole to 10 or 14 days improves the rate of H. pylori eradication by 5% to 10% 3.

Alternative Treatment Regimens

• Bismuth quadruple therapy is recommended as the best initial empiric treatment due to the declining efficacy of legacy triple therapies 4.
• Concomitant, sequential, and hybrid therapies are remarkable bismuth-free quadruple options, provided that dual clarithromycin-metronidazole resistance is low 4.
• Levofloxacin-, rifabutin-, furazolidone-, and sitafloxacin-containing regimens remain useful, particularly as salvage options 4.
• A fixed-dose combination of bismuth subcitrate potassium + metronidazole + tetracycline is authorized in the European Union for use in combination with omeprazole for 10 days 3.

Efficacy and Safety of Treatment Regimens

• A 5-day quadruple therapy with omeprazole, metronidazole, clarithromycin, and amoxicillin represents an effective and safe new regimen for H. pylori eradication 5.
• Azithromycin, ofloxacin, bismuth, and omeprazole as second-line therapy has been shown to be effective and safe in patients with H. pylori infection 6.
• The incidence of poor compliance and adverse events was lower in patients treated with azithromycin, ofloxacin, bismuth, and omeprazole compared to those treated with amoxicillin, clarithromycin, bismuth, and omeprazole 6.

Diagnostic and Management Strategies

• The "test-and-treat" strategy is the recommended approach for healthcare practitioners when managing H. pylori infection 7.
• The choice of testing method should be based on several factors, including patient age, presenting symptoms, and medication use, as well as test reliability, availability, and cost 7.
• Once treated, it is essential to test for eradication as untreated H. pylori is associated with serious complications, including peptic ulcer disease, mucosa-associated lymphoid tissue lymphoma, and gastric cancer 7.