What is the recommended therapy for Helicobacter Pylori (H Pylori) infection?

From the Guidelines

The recommended first-line therapy for Helicobacter pylori infection is a 14-day course of bismuth quadruple therapy or concomitant therapy, depending on the local prevalence of resistant organisms and previous antibiotic exposure, as this approach has been shown to achieve high eradication rates and minimize the risk of antibiotic resistance 1.

Key Considerations

• The choice of first-line therapy should be based on the local prevalence of resistant organisms, with bismuth quadruple therapy preferred in areas with high dual resistance to clarithromycin and metronidazole 1.
• Concomitant therapy is a suitable alternative in areas with high clarithromycin resistance where bismuth is not available 1.
• The duration of first-line therapy should be 14 days, as this has been shown to achieve higher success rates than shorter durations 1.

Treatment Options

• Bismuth quadruple therapy: a proton pump inhibitor (PPI), bismuth subsalicylate, tetracycline, and metronidazole for 14 days.
• Concomitant therapy: a PPI, amoxicillin, clarithromycin, and metronidazole for 14 days.

Special Considerations

• Patients allergic to penicillin can be treated with metronidazole instead of amoxicillin.
• In areas with low clarithromycin resistance, standard triple therapy may still be effective as a first-line treatment 1.

Testing and Follow-up

• Patients should be tested to confirm eradication after completing treatment, typically using a urea breath test or stool antigen test performed at least 4 weeks after therapy completion and while off PPI therapy for at least 2 weeks.

From the FDA Drug Label

1. 4 Dosage for H. pyloriInfection in Adults Triple therapy:The recommended adult oral dose is 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily (every 12 hours) for 14 days. Dual therapy:The recommended adult oral dose is 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily (every 8 hours) for 14 days.

The recommended therapy for H. pylori infection in adults is either triple therapy or dual therapy.

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

From the Research

Recommended Therapy for H Pylori Infection

The recommended therapy for Helicobacter Pylori (H Pylori) infection includes:

• First-line therapy: a proton pump inhibitor (PPI) or ranitidine bismuth citrate, with any two antibiotics among amoxicillin, clarithromycin, and metronidazole, given for 7-14 days 3
• First-line strategies: concomitant nonbismuth quadruple therapy (PPI + amoxicillin + metronidazole + clarithromycin) and traditional bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline) 4
• Alternative first-line therapy: PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole) can be used in areas with known low clarithromycin resistance or high eradication success with these regimens 4

Second-Line Therapy

• Recommended second-line therapy: a quadruple regimen composed of tetracycline, metronidazole, a bismuth salt, and a PPI 3
• Alternative second-line therapy: the combination of PPI-amoxicillin-levofloxacin is a good option as second-line therapy 3
• Rescue therapies: levofloxacin-containing therapy (PPI + amoxicillin + levofloxacin) and bismuth-based quadruple therapies have been shown to be effective second-line regimens 4, 5

Third-Line Therapy

• Third-line options: regimes based on rifabutin or furazolidone, but susceptibility testing is the most rational option here 5
• Alternative third-line therapy: high-dose PPI/amoxicillin therapy might also be promising 3
• The choice of third-line therapy should be based on a case-by-case approach, taking into account the patient's previous treatment history and antibiotic resistance patterns 3

Treatment Duration and Efficacy

• Treatment duration: all H pylori eradication regimens should be given for 14 days 4
• Efficacy: both PAC (proton-pump inhibitor and amoxicillin-based triple therapy containing clarithromycin) and PAM (proton-pump inhibitor and amoxicillin-based triple therapy containing metronidazole) regimens are effective and comparable in eradicating H pylori, but PAM showed greater efficacy than PAC in recent years, especially for people over 60 years old 6