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

From the Guidelines

The best treatment for H. pylori infection is 14-day bismuth quadruple therapy, which is the recommended first-line therapy when susceptibility testing or regional data are not available. This approach is supported by recent guidelines that prioritize avoiding antibiotic overuse and reducing the risk of resistance 1. The bismuth quadruple therapy regimen typically consists of a proton pump inhibitor (PPI) such as omeprazole 20mg twice daily, plus two antibiotics—usually amoxicillin 1000mg twice daily and clarithromycin 500mg twice daily, and bismuth subsalicylate (525mg four times daily) 1.

Some key points to consider when treating H. pylori infection include:

• The importance of avoiding antibiotic overuse and reducing the risk of resistance 1
• The need to succeed on the first attempt to avoid retreating and retesting, and reducing cost, anxiety, and negative impacts on other gut microbiota 1
• The recommendation for 14-day treatment duration, which has been shown to have higher success rates compared to shorter durations 1
• The use of bismuth quadruple therapy in areas with high dual resistance to clarithromycin and metronidazole, or in patients who have previously failed treatment 1

It is also important to note that after completing treatment, patients should be tested to confirm eradication, typically using a urea breath test or stool antigen test performed at least 4 weeks after therapy and while off PPI medications for at least 2 weeks 1. Successful eradication helps prevent recurrent peptic ulcers, reduces gastric cancer risk, and resolves symptoms in many patients with functional dyspepsia related to H. pylori infection.

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 best treatment for Helicobacter pylori (H. pylori) infection is:

• 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 whom resistance to clarithromycin is known or suspected) 2

From the Research

Treatment Options for H. pylori Infection

The treatment of Helicobacter pylori (H. pylori) infection typically involves a combination of antibiotics and a proton pump inhibitor (PPI) 3, 4, 5, 6, 7. The choice of treatment regimen depends on various factors, including the local prevalence of clarithromycin resistance and the patient's previous use of macrolides 5.

First-Line Treatment Regimens

• Quadruple therapies, such as bismuth quadruple and concomitant therapy, are recommended as first-line treatment regimens 5, 6, 7.
• 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 5.
• Proton-pump inhibitor and amoxicillin-based triple therapy, including clarithromycin (PAC) and metronidazole (PAM), are also effective first-line treatment regimens 3.

Second-Line Treatment Regimens

• Levofloxacin-containing triple therapy and bismuth quadruple therapy are recommended as second-line treatment regimens 5, 6.
• Sequential therapy is not generally recommended due to contradictory data on its efficacy against clarithromycin-resistant H. pylori strains 5.

Factors Affecting Treatment Efficacy

• Antibiotic resistance is a major cause of treatment failure 4, 6.
• Patient compliance is also an important factor in determining treatment success 6.
• The use of probiotic supplementation may help reduce antibiotic-related adverse events 5.

Eradication Rates

• The eradication rates of different treatment regimens vary, with quadruple therapy achieving the highest eradication rates (up to 96%) 7.
• PPI triple therapies have been shown to be very effective against H. pylori, with eradication rates of 80-89% 7.
• Bismuth triple therapy continues to reach high eradication rates worldwide, with a mean eradication rate of 78-89% 7.