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 twice daily, combined with two antibiotics—clarithromycin 500mg twice daily and either amoxicillin 1g twice daily or metronidazole 500mg twice daily—for 10-14 days.
• In areas with high clarithromycin resistance, bismuth-based quadruple therapy may be preferred, which includes a PPI, bismuth subsalicylate (525mg four times daily), tetracycline (500mg four times daily), and metronidazole (500mg three times daily) for 10-14 days.

Rationale for Treatment

This combination approach is necessary because H. pylori can develop antibiotic resistance, and the bacteria live beneath the gastric mucus layer where single antibiotics cannot effectively reach.

• The PPI reduces stomach acid production, creating a less acidic environment that enhances antibiotic effectiveness and promotes healing of any ulcers present.
• The use of high-dose and more potent PPIs, PPIs not metabolized by CYP2C19 or potassium-competitive acid blockers if available, should be considered in cases of refractory H. pylori infection, as suggested by 1.

Treatment Success and Follow-up

Treatment success should be confirmed with a urea breath test, stool antigen test, or endoscopy at least 4 weeks after completing therapy and after PPI discontinuation for at least 2 weeks.

• Longer treatment durations provide higher eradication success rates compared to shorter durations (e.g. 14 days vs 7 days), as suggested by 1.
• In some cases, there should be shared decision-making regarding ongoing attempts to eradicate H. pylori, weighing the potential benefits of H. pylori eradication against the likelihood of adverse effects, 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. Some of the effective treatment options include:

• A combination of metronidazole, omeprazole, and clarithromycin for 2 weeks, followed by ranitidine for 4 weeks, which has been shown to cure H. pylori infection in 88% of patients 3
• A 10-day quadruple nonbismuth containing regimen consisting of esomeprazole, metronidazole, amoxicillin, and clarithromycin, which has been found 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
• Dual therapy with clarithromycin and omeprazole, which has reported eradication rates of between 58 and 83% 5
• One-week triple therapy with omeprazole, amoxycillin, and either clarithromycin or metronidazole, which has been shown to be effective in eradicating H. pylori infection, with eradication rates of 88% and 78% respectively 6

Factors Affecting Treatment Success

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

• Antibiotic resistance, which can reduce the effectiveness of treatment 4, 7
• Patient compliance, which is essential for successful treatment 4, 7
• 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/proton-pump inhibitor regimen, which has been found to be effective in eradicating H. pylori, with an eradication rate of 93.6% in per-protocol analysis 7