What is the recommended treatment for Helicobacter pylori infection?

From the Guidelines

The recommended treatment for Helicobacter pylori infection is a combination therapy approach known as triple or quadruple therapy, with the first-line treatment typically consisting of a proton pump inhibitor (PPI) such as omeprazole 20mg twice daily, combined with two antibiotics—usually amoxicillin 1g twice daily and clarithromycin 500mg twice daily—for 10-14 days, 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, with areas of high clarithromycin resistance requiring alternative therapies 1.
• In areas with low clarithromycin resistance, standard triple therapy is recommended as first-line therapy, while in areas with high clarithromycin resistance, bismuth-based quadruple therapy or non-bismuth quadruple therapy may be used as first-line therapy 1.
• Patients should complete the entire course of treatment even if symptoms improve before completion, and eradication should be confirmed with either a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and after stopping PPI for at least 2 weeks.

Treatment Options

• First-line therapy:
  • Standard triple therapy (PPI, amoxicillin, and clarithromycin) for 10-14 days
  • Bismuth-based quadruple therapy (PPI, bismuth subsalicylate, tetracycline, and metronidazole) for 10-14 days
• Second-line therapy:
  • Levofloxacin-based triple therapy (PPI, amoxicillin, and levofloxacin) for 10-14 days

Important Notes

• Combination therapy is necessary because H. pylori can develop resistance to single antibiotics, and the PPI both reduces acid production to help heal ulcers and creates a less acidic environment where antibiotics can work more effectively.
• The most recent guidelines recommend a proactive approach to testing and treatment of H. pylori, 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

DOSAGE AND ADMINISTRATION 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 recommended treatment for Helicobacter pylori infection in adults is:

• 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

Treatment Options for Helicobacter pylori Infection

The recommended treatment for Helicobacter pylori infection varies depending on several factors, including the local prevalence of clarithromycin resistance and the patient's previous use of macrolides.

• First-line treatment:
  • Quadruple therapies (bismuth quadruple and concomitant) are recommended regimens for the first-line treatment 3
  • A 14-day clarithromycin-containing triple therapy is suggested in areas with low prevalence of clarithromycin resistance and in patients without previous use of macrolides 3
• Second-line treatment:
  • Levofloxacin-containing triple therapy and bismuth quadruple therapy are recommended second-line treatments 3
  • Sequential therapy is not generally recommended due to contradictory data on its efficacy against clarithromycin-resistant H. pylori strains 3
• Other treatment options:
  • Probiotic supplementation can be used to reduce antibiotic-related adverse events 3
  • Rifabutin or furazolidone-based regimes can be used as third-line options, but susceptibility testing is recommended 4

Efficacy of Different Treatment Regimens

Studies have shown that different treatment regimens have varying efficacy in eradicating H. pylori infection.

• A study published in 2009 found that the recommended first-line treatment regimen of proton pump inhibitor, amoxicillin, and clarithromycin had falling eradication rates due to antibiotic resistance and poor compliance 4
• A study published in 2021 found that quadruple therapies were effective first-line treatments, with eradication rates ranging from 90% to 95% 3
• A study published in 1998 found that a quadruple therapy regimen consisting of omeprazole, metronidazole, clarithromycin, and amoxicillin had an eradication rate of 96% 5
• A study published in 1996 found that a triple therapy regimen consisting of omeprazole, clarithromycin, and amoxicillin had an eradication rate of 89.6% to 95.7% 6
• A study published in 2012 found that a first-line regimen consisting of proton pump inhibitor, metronidazole, and amoxicillin was more effective than a regimen consisting of proton pump inhibitor, clarithromycin, and amoxicillin, with eradication rates of 96.4% to 100% versus 74.5% to 80.4% 7