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

From the Guidelines

The recommended treatment for Helicobacter pylori infection is a 14-day bismuth quadruple therapy as first-line therapy, which includes a proton pump inhibitor (PPI), bismuth subsalicylate, tetracycline, and metronidazole, as it is the most effective approach in the face of increasing antibiotic resistance, as suggested by the most recent and highest quality study 1.

Treatment Approach

The treatment of H. pylori infection typically involves a combination therapy approach known as triple or quadruple therapy.

• The first-line treatment usually consists of a PPI such as omeprazole 20mg or esomeprazole 40mg twice daily,
• plus two antibiotics—commonly amoxicillin 1g twice daily and clarithromycin 500mg twice daily—for 10-14 days.
• For patients allergic to penicillin, metronidazole 500mg twice daily can replace amoxicillin.

Alternative Therapies

In areas with high clarithromycin resistance or after failed first-line therapy,

• bismuth-based quadruple therapy is recommended,
• which includes a PPI, bismuth subsalicylate (525mg four times daily), tetracycline (500mg four times daily), and metronidazole (250-500mg three to four times daily) for 10-14 days.

Treatment Duration and Confirmation

Patients should complete the entire course of treatment even if symptoms improve before completion.

• Confirmation of eradication through urea breath test, stool antigen test, or endoscopy with biopsy should be performed at least 4 weeks after completing therapy and after stopping PPI for at least 2 weeks, as recommended by 1 and 1.

Rationale for Treatment Approach

This aggressive combination approach is necessary because H. pylori can develop antibiotic resistance and forms a protective biofilm in the stomach lining, making it difficult to eradicate with single-agent therapy, as highlighted by 1.

Considerations for Refractory Infection

In cases of refractory H. pylori infection,

• providers should attempt to identify other contributing etiologies,
• including inadequate adherence to therapy and insufficient gastric acid suppression,
• and consider alternative therapies such as levofloxacin- or rifabutin-based triple therapy regimens, as suggested by 1.

From the FDA Drug Label

2.4 Dosage for H. pylori Infection 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 treatment for Helicobacter pylori (H. pylori) infection is:

• Triple therapy: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days.
• Dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days 2. Key points:
• The treatment should be used to treat infections that are proven or strongly suspected to be caused by bacteria.
• The effectiveness of amoxicillin and other antibacterial drugs should be maintained by using them only to treat infections that are proven or strongly suspected to be caused by bacteria 2.

From the Research

H. pylori Treatment Options

The recommended treatment for Helicobacter pylori (H. pylori) infection typically involves a combination of antibiotics and a proton pump inhibitor (PPI) to reduce stomach acid. Some effective treatment options include:

• A 2-week regimen of metronidazole, omeprazole, and clarithromycin, which has been shown to cure H. pylori infection in 88% of patients 3
• A 10-day regimen of esomeprazole, metronidazole, amoxicillin, and clarithromycin, which has been shown to be effective in eradicating H. pylori in a high clarithromycin resistance area, with an eradication rate of 91.5% in first-line treatment and 60.6% in second-line treatment 4
• A 1-week triple therapy regimen of omeprazole, amoxycillin, and either clarithromycin or metronidazole, which has been shown to be effective in eradicating H. pylori, with eradication rates of 88% and 78%, respectively 5

Factors Affecting Treatment Success

Several factors can affect the success of H. pylori treatment, including:

• Antibiotic resistance, which can reduce the effectiveness of treatment 4, 6
• Patient compliance, which is essential for successful treatment 4, 6
• The presence of dual antibiotic resistance, which can compromise the effectiveness of treatment 4

Second-Line Treatment Options

For patients who fail first-line treatment, second-line treatment options are available, including:

• A 14-day levofloxacin/amoxicillin/esomeprazole regimen, which has been shown to be effective in eradicating H. pylori, with an eradication rate of 93.6% in per-protocol analysis 6
• A 14-day esomeprazole/metronidazole/bismuth salt/tetracycline regimen, which has been shown to be effective in eradicating H. pylori, with an eradication rate of 91.8% in per-protocol analysis 6