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

From the Guidelines

The first-line treatment for Helicobacter pylori infection should be a 14-day concomitant non-bismuth quadruple therapy regimen, consisting of a proton pump inhibitor (PPI) such as omeprazole 20 mg twice daily, amoxicillin 1000 mg twice daily, metronidazole 500 mg twice daily, and clarithromycin 500 mg twice daily, as recommended by all guidelines 1. This regimen is preferred due to its high efficacy and broad coverage against H. pylori strains. The use of a quadruple therapy regimen is supported by the Toronto Consensus, Maastricht V/Florence, and American College of Gastroenterology recommendations, which all suggest that 14 days would be the preferred length of first-line therapy 1. Some key points to consider when selecting a treatment regimen include:

• The choice of PPI, with standard doses including dexilant 30 mg, esomeprazole 20 mg, lansoprazole 30 mg, omeprazole 20 mg, pantoprazole 40 mg, and rabeprazole 20 mg, although a double dose is sometimes used to increase eradication success 1.
• The potential for antibiotic resistance, particularly to clarithromycin and levofloxacin, which highlights the need for surveillance registries for H. pylori resistance and local therapy success rates 1.
• The importance of confirming eradication with either a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and after PPI discontinuation for at least 2 weeks. In patients with true penicillin allergy, bismuth quadruple therapy is recommended as an alternative first-line option, consisting of a PPI twice daily, bismuth subsalicylate 525 mg four times daily, tetracycline 500 mg four times daily, and metronidazole 500 mg three times daily for 14 days 1. If the initial treatment fails, a rescue regimen such as levofloxacin-based triple therapy or rifabutin-containing therapy may be considered, although the choice of rescue regimen should be guided by individual patient factors and local resistance patterns 1.

From the FDA Drug Label

Dosing for H. pylori Infection (in Adults): Triple therapy: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily (every 12 hours) for 14 days. Dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, all given three times daily (every 8 hours) for 14 days. The H. pylori treatment regimen includes two options:

• Triple therapy: 1 gram of amoxicillin, 500 mg of clarithromycin, and 30 mg of lansoprazole, all given twice daily for 14 days.
• Dual therapy: 1 gram of amoxicillin and 30 mg of lansoprazole, all given three times daily for 14 days 2.

From the Research

H pylori Treatment Regimen

• The recommended first-line strategies for H pylori eradication include concomitant nonbismuth quadruple therapy (proton pump inhibitor [PPI] + amoxicillin + metronidazole + clarithromycin [PAMC]) and traditional bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline [PBMT]) 3.
• PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole) is restricted to areas with known low clarithromycin resistance or high eradication success with these regimens 3.
• Recommended rescue therapies include PBMT and levofloxacin-containing therapy (PPI + amoxicillin + levofloxacin) 3.
• Rifabutin regimens should be restricted to patients who have failed to respond to at least 3 prior options 3.
• A new, short quadruple therapy for Helicobacter pylori eradication, including amoxicillin, metronidazole, omeprazole, and clarithromycin, has been shown to be effective and safe 4.
• Due to the declining efficacy of legacy triple therapies, most guidelines recommend bismuth quadruple therapy as the best initial empiric treatment 5.
• Concomitant, sequential, and hybrid therapies are remarkable bismuth-free quadruple options, provided that dual clarithromycin-metronidazole resistance is low 5.
• The recommended first-line treatment in published guidelines in Europe and North America is proton pump inhibitor combined with amoxicillin and clarithromycin 6.
• Bismuth-based quadruple therapies and levofloxacin-based regimes have been shown to be effective second-line regimens 6.
• In regions with low (≦15%) clarithromycin resistance, 14-day hybrid (or reverse hybrid), 10 ~ 14-day sequential, 7 ~ 14-day concomitant, 10 ~ 14-day bismuth quadruple or 14-day triple therapy can achieve a high eradication rate in the first-line treatment of H pylori infection 7.
• In areas with high (>15%) clarithromycin resistance, standard triple therapy should be abandoned because of low eradication efficacy, and 14-day hybrid (or reverse hybrid), 10 ~ 14-day concomitant or 10 ~ 14-day bismuth quadruple therapy are the recommended regimens 7.

Treatment Duration

• The consensus group strongly recommends that all H pylori eradication regimens now be given for 14 days 3.
• A 5-day quadruple therapy (with omeprazole, metronidazole, clarithromycin, and amoxicillin) has been shown to be effective and safe 4.
• Treatment duration of 7 ~ 14 days is commonly recommended for various regimens 3, 7.

Treatment Considerations

• Optimal treatment of H pylori infection requires careful attention to local antibiotic resistance and eradication patterns 3.
• Susceptibility-guided treatment appears as the ideal approach, but the feasibility and cost-effectiveness of universal pre-treatment susceptibility testing warrants further evaluation 5.
• Molecular testing methods promise convenient characterization of H pylori antibiotic susceptibility 5.
• Addition of certain probiotics could somewhat increase the performance of H pylori eradication regimens, while improving tolerability 5.