What is the management of Helicobacter pylori (H. pylori) infection?

From the Guidelines

The management of Helicobacter pylori infection should start with a standard triple therapy regimen, including a proton pump inhibitor (PPI), amoxicillin, and clarithromycin, for 14 days, as recommended by recent guidelines 1. The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community.

• In areas with low clarithromycin resistance, the standard triple therapy regimen is recommended as first-line therapy 1.
• In areas with high clarithromycin resistance, quadruple therapy or sequential therapy may be considered as alternative options 1.
• If first-line therapy fails, a second-line therapy, such as a 10-day levofloxacin-amoxicillin triple therapy, may be recommended 1. The treatment regimen should be chosen based on the patient's specific needs and the local resistance patterns.
• The doses of the medications should be as follows: PPI standard dose twice a day, amoxicillin 1000 mg twice a day, clarithromycin 500 mg twice a day, and metronidazole 500 mg twice a day 1.
• Lifestyle modifications during treatment include avoiding alcohol and taking probiotics to reduce antibiotic-associated side effects. It is essential to confirm eradication of H. pylori after completing treatment, using either a urea breath test, stool antigen test, or endoscopic biopsy, typically 4 weeks after therapy and after PPI discontinuation for 2 weeks 1. The most recent and highest quality study, published in 2022, recommends a proactive approach to testing and treatment of H. pylori, including outreach to family members of individuals diagnosed with active infection and high-risk local populations 1. However, the 2021 study provides more detailed information on the management of refractory H. pylori infection, which is essential for clinical practice 1. Therefore, the 2021 study is the most relevant and highest quality study for guiding the management of H. pylori infection.

From the FDA Drug Label

Duodenal Ulcer Associated with H. pylori Infection Clarithromycin + Lansoprazole and Amoxicillin H. pylori Eradication for Reducing the Risk of Duodenal Ulcer Recurrence Two U. S. randomized, double-blind clinical studies in patients with H. pylori and duodenal ulcer disease (defined as an active ulcer or history of an active ulcer within one year) evaluated the efficacy of clarithromycin in combination with lansoprazole and amoxicillin capsules as triple 14-day therapy for eradication of H. pylori Based on the results of these studies, the safety and efficacy of the following eradication regimen were established: Triple therapy: clarithromycin 500 mg b.i.d. + lansoprazole 30 mg b.i.d. + amoxicillin 1 gm b.i. d. Treatment was for 14 days. H. pylori eradication was defined as two negative tests (culture and histology) at 4 to 6 weeks following the end of treatment.

The management of Helicobacter pylori (H. pylori) infection involves a combination of medications, including:

• Clarithromycin: 500 mg twice daily
• Lansoprazole: 30 mg twice daily
• Amoxicillin: 1 gram twice daily This triple therapy regimen is administered for 14 days to eradicate H. pylori and reduce the risk of duodenal ulcer recurrence 2. Alternatively, a triple therapy regimen of clarithromycin, omeprazole, and amoxicillin can also be used 2. Another option is a dual therapy regimen of amoxicillin and lansoprazole, administered three times daily for 14 days 3.

From the Research

Management of H. pylori Infection

The management of Helicobacter pylori (H. pylori) infection typically involves a combination of antibiotics and acid suppressors.

• The goal of treatment is to eradicate the infection, which can help to cure peptic ulcer disease and reduce the risk of gastric cancer.
• Several treatment regimens have been studied, including triple therapy with two antibiotics and an acid suppressor, and quadruple therapy with three antibiotics and an acid suppressor.

Treatment Regimens

Some of the treatment regimens that have been studied include:

• Amoxicillin, metronidazole, and omeprazole, with or without clarithromycin 4
• Metronidazole, omeprazole, and clarithromycin 5
• Omeprazole, amoxicillin, and clarithromycin, with or without levofloxacin or metronidazole and bismuth 6
• Esomeprazole, amoxicillin, clarithromycin, and metronidazole 7
• Clarithromycin and omeprazole, with or without amoxicillin or a nitroimidazole 8

Efficacy of Treatment Regimens

The efficacy of these treatment regimens has been evaluated in several studies, with eradication rates ranging from 70% to over 95%:

• A study of quadruple therapy with amoxicillin, metronidazole, omeprazole, and clarithromycin found an eradication rate of 96% 4
• A study of triple therapy with metronidazole, omeprazole, and clarithromycin found an eradication rate of 88% 5
• A study of three different treatment regimens, including omeprazole, amoxicillin, and clarithromycin, found eradication rates of 82%, 91%, and 97% 6
• A study of hybrid therapy with esomeprazole, amoxicillin, clarithromycin, and metronidazole found an eradication rate of 99% 7
• A review of studies on dual therapy with clarithromycin and omeprazole found an eradication rate of approximately 70% 8

Adverse Events

Adverse events have been reported with these treatment regimens, including:

• Taste disturbance, nausea, headache, diarrhea, vomiting, and abdominal pain 8
• The incidence of adverse events has been reported to be around 45% with dual therapy, and has been found to be similar with triple therapy 8