From the Guidelines
For patients with Helicobacter pylori infection who have an amoxicillin allergy, the recommended treatment is a bismuth quadruple therapy regimen, consisting of a proton pump inhibitor (PPI) twice daily, bismuth subsalicylate 525 mg four times daily, metronidazole 500 mg three times daily, and tetracycline 500 mg four times daily for 14 days, as this regimen has been shown to be effective in eradicating H. pylori while avoiding the use of amoxicillin 1.
Key Considerations
- The bismuth quadruple therapy regimen is preferred due to its lower resistance rates compared to fluoroquinolone-based regimens 1.
- The regimen should be taken for 14 days, as this duration has been shown to be superior to 10-day regimens in terms of eradication rates 1.
- The PPI dose depends on the specific medication used, 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 may be used to increase eradication success 1.
- Metronidazole may be substituted with tinidazole, and the bismuth dose depends on the formulation used 1.
Alternative Regimens
- A levofloxacin-based triple therapy regimen, consisting of a PPI twice daily, levofloxacin 500 mg once daily, and clarithromycin 500 mg twice daily for 14 days, may be used as an alternative 1.
- However, this regimen is not preferred due to higher resistance rates compared to the bismuth quadruple therapy regimen 1.
Follow-up
- After completing treatment, patients should undergo a urea breath test, stool antigen test, or biopsy-based testing at least 4 weeks after therapy (and after PPIs have been stopped for 2 weeks) to confirm eradication 1.
- This is particularly important in patients with complicated ulcers, MALT lymphoma, or persistent symptoms.
From the Research
H pylori Treatment with Amoxicillin Allergy
- The recommended treatment for H pylori infection in patients with an allergy to amoxicillin is not clearly defined, but several alternatives have been studied 2, 3, 4.
- First-line therapy for H pylori infection typically includes clarithromycin triple therapy, bismuth quadruple therapy, or concomitant therapy, but these regimens often include amoxicillin or other penicillins, making them unsuitable for patients with amoxicillin allergies 2.
- For patients allergic to penicillin, a first-line treatment with omeprazole, clarithromycin, and metronidazole has been shown to have low efficacy, with per-protocol and intention-to-treat eradication rates of 55% and 54%, respectively 4.
- A levofloxacin-containing regimen, combined with omeprazole and clarithromycin, has been proposed as a second-line alternative for patients with penicillin allergy, with per-protocol and intention-to-treat eradication rates of 73% 4.
- Another study evaluated the efficacy of triple therapy with a proton pump inhibitor, levofloxacin, and amoxicillin as a first-line treatment, but this regimen is not suitable for patients with amoxicillin allergies 5.
- Bismuth-based quadruple therapy has also been recommended as a first-line regimen in areas with high rates of clarithromycin and metronidazole resistance, and as a second-line option otherwise 3.
Alternative Treatment Options
- Omeprazole, clarithromycin, and metronidazole may be considered as a first-line treatment for patients with amoxicillin allergies, although its efficacy is relatively low 4.
- Levofloxacin-containing regimens may be considered as a second-line alternative for patients with penicillin allergy 4.
- Bismuth-based quadruple therapy may be considered as a first-line or second-line treatment option, depending on the local resistance patterns 3.