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

From the Guidelines

The standard first-line therapy for H. pylori infection is triple therapy, which includes a proton pump inhibitor (PPI) such as omeprazole 20mg twice daily, plus two antibiotics: clarithromycin 500mg twice daily and either amoxicillin 1000mg twice daily or metronidazole 500mg twice daily, as recommended by the most recent guidelines 1.

Key Considerations

• The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community, as the response to eradication therapy is significantly related to the prevalence of primary resistance in the population 1.
• In areas with high clarithromycin resistance, quadruple therapy may be used first-line, consisting of a PPI, bismuth subsalicylate, tetracycline, and metronidazole 1.
• The combination therapy approach is necessary because H. pylori can develop resistance to single antibiotics, and the PPI helps both reduce acid production and enhances antibiotic effectiveness.

Treatment Duration and Follow-up

• The treatment duration is typically 10-14 days, with longer treatment durations providing higher eradication success rates compared to shorter durations 1.
• After treatment, patients should be tested to confirm eradication, typically using a urea breath test, stool antigen test, or endoscopy with biopsy at least 4 weeks after completing therapy and while off PPI medications for at least 2 weeks.

Importance of H. pylori Eradication

• H. pylori eradication is crucial as the bacterium can cause chronic gastritis, peptic ulcers, and is associated with gastric cancer.
• A proactive approach to testing and treatment of H. pylori is now recommended, including outreach to family members of individuals diagnosed with active infection as well as high-risk local populations such as immigrants from high-risk countries 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.

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

• Bismuth quadruple therapy is recommended as the best initial empiric treatment due to the declining efficacy of legacy triple therapies 3
• Concomitant, sequential, and hybrid therapies are remarkable bismuth-free quadruple options, provided that dual clarithromycin-metronidazole resistance is low 3
• Levofloxacin-, rifabutin-, furazolidone-, and sitafloxacin-containing regimens remain useful, particularly as salvage options 3

Proton-Pump Inhibitor and Amoxicillin-Based Triple Therapy

• Proton-pump inhibitor and amoxicillin-based triple therapy containing clarithromycin (PAC) and metronidazole (PAM) are two commonly used first-line therapies for H. pylori infection 4
• The pooled risk ratios between the PAC and PAM groups were comparable in the intention-to-treat (ITT) eradication rates and per-protocol (PP) eradication rates 4
• PAM is highly effective in clarithromycin-resistant cases, and PAC showed significant efficacy in metronidazole-resistant cases 4

Alternative Therapy Options

• High-dose dual therapy (proton-pump-inhibitor plus amoxicillin) and vonoprazan, a more potent acid inhibitor, are promising alternatives that could decrease misuse of antibiotics 3
• Addition of certain probiotics could somewhat increase the performance of H. pylori eradication regimens, while improving tolerability 3
• Pantoprazole- or lansoprazole-based clarithromycin plus amoxicillin treatment has shown moderate success in eradicating H. pylori 5

Diagnostic and Management Strategies

• The "test-and-treat" strategy is the recommended approach for healthcare practitioners when managing H. pylori infection 6
• 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 6
• 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 6