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

From the Guidelines

The first-line treatment for Helicobacter pylori infection is typically a clarithromycin-based triple therapy consisting of a proton pump inhibitor (PPI) such as omeprazole 20 mg twice daily, clarithromycin 500 mg twice daily, and amoxicillin 1 gram twice daily, all taken for 14 days, as recommended by the most recent guidelines 1.

Treatment Regimens

The treatment regimen should be chosen based on the local prevalence of resistant strains, with bismuth quadruple therapy or non-bismuth quadruple therapy considered in areas with high clarithromycin resistance 1. The standard triple therapy regimen includes:

• PPI standard dose twice a day
• Clarithromycin 500 mg twice a day
• Amoxicillin 1000 mg twice a day

Alternative Options

In areas with high clarithromycin resistance, alternative first-line options include:

• Bismuth quadruple therapy (PPI, bismuth subsalicylate, tetracycline, and metronidazole)
• Non-bismuth quadruple therapy (concomitant therapy with PPI, amoxicillin, clarithromycin, and metronidazole) 1

Duration of Treatment

The duration of treatment is typically 14 days, with some guidelines recommending 10-14 days for certain regimens 1.

Confirmation of Treatment Success

Treatment success should be confirmed with 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 1.

Importance of Eradication

Eradication of H. pylori is important to prevent recurrent peptic ulcers, gastritis, and reduce the risk of gastric cancer 1.

Resistance and Future Directions

The increasing resistance of H. pylori to antibiotic therapy necessitates local availability of susceptibility tests and establishment of regional and national monitoring programs to develop evidence-based locally relevant eradication strategies 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. 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.

The first line treatment for Helicobacter pylori (H pylori) infection is triple therapy consisting of:

• Amoxicillin 1 gram,
• Clarithromycin 500 mg, and
• Lansoprazole 30 mg, all given twice daily for 14 days 2.

Alternatively, dual therapy with amoxicillin and lansoprazole can be used in patients who are allergic or intolerant to clarithromycin or in whom resistance to clarithromycin is known or suspected 2.

From the Research

First Line Treatment for H pylori Infection

The first line treatment for Helicobacter pylori (H pylori) infection is a topic of ongoing research and debate.

• 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 also considered as 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.

Treatment Options

Other treatment options include:

• Proton-pump inhibitor and amoxicillin-based triple therapy containing clarithromycin or metronidazole, which have comparable eradication rates 4.
• A new, short quadruple therapy consisting of amoxicillin, metronidazole, omeprazole, and clarithromycin, which has been shown to be effective and safe 5.
• Triple therapy consisting of two antibiotics, such as clarithromycin and amoxicillin or metronidazole, in combination with a proton pump inhibitor (PPI) 6.

Recent Strategies

Recent strategies for optimal first-line treatment include:

• Selecting the most appropriate regimen depending on resistance, but identifying resistance to specific antibiotics is clinically challenging 7.
• Bismuth quadruple therapy and nonbismuth quadruple therapies, such as sequential, concomitant, and sequential-concomitant hybrid, as first-line regimen options in regions with high clarithromycin resistance 7.
• Tailored therapy based on antibiotic sensitivity testing, which would be optimal but has several limitations for clinical use 7.