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

Recommended Treatment for Helicobacter pylori Infection

The first-line treatment for H. pylori infection should be bismuth quadruple therapy for 14 days, especially in areas with high clarithromycin resistance (>15-20%). 1 This approach provides the highest eradication rates in the current era of increasing antibiotic resistance.

First-Line Treatment Options

Preferred First-Line Therapy

• Bismuth quadruple therapy (14 days) 1
  • Bismuth salt + PPI (40 mg rabeprazole or esomeprazole twice daily) + Tetracycline + Metronidazole
  • Take PPI 30 minutes before meals and at bedtime
  • This regimen is effective even against metronidazole-resistant strains

Alternative First-Line Options

1. Rifabutin triple therapy (14 days) 1

   • Rifabutin 150 mg twice daily
   • Amoxicillin 1 g three times daily
   • PPI (40 mg esomeprazole or rabeprazole twice daily) 30 minutes before meals

2. Talicia® formulation (pre-packaged rifabutin triple therapy) for 14 days 1

PPI Selection and Dosing

• Use high-potency PPIs at adequate doses 1
• Recommended PPIs: Esomeprazole or rabeprazole 20-40 mg twice daily
• Avoid: Pantoprazole (significantly less potent)
• PPI potency comparison:
  • 40 mg pantoprazole = 9 mg omeprazole
  • 20 mg rabeprazole = 36 mg omeprazole
  • 20 mg esomeprazole = 32 mg omeprazole

Treatment Based on Antibiotic Susceptibility

For Known Susceptibility

If susceptibility testing is available, these regimens may be used when appropriate 1:

• Clarithromycin triple therapy (14 days)

  • Only when clarithromycin susceptibility is confirmed
  • Clarithromycin 500 mg twice daily
  • Amoxicillin 1 g twice daily
  • PPI (high dose) twice daily

• Metronidazole triple therapy (14 days)

  • Only when metronidazole susceptibility is confirmed
  • Metronidazole 500 mg twice daily
  • Amoxicillin 1 g twice daily
  • PPI (high dose) twice daily

Second-Line Treatment

After failure of a PPI-clarithromycin containing therapy 1:

• Bismuth-containing quadruple therapy
• Levofloxacin-containing triple therapy

Important Considerations

Factors Affecting Treatment Success

• Prior treatment failure: Significantly reduces eradication rates 2
• Antibiotic resistance: Primary cause of treatment failure 1
• PPI dosing: Higher doses improve eradication rates 1
• Treatment duration: 14-day regimens are superior to 7-day regimens 1

Common Pitfalls to Avoid

1. Using clarithromycin triple therapy empirically in areas with >15-20% clarithromycin resistance 1
2. Inadequate PPI dosing - use high-dose, high-potency PPIs 1
3. Short treatment duration - 14 days is optimal for most regimens 1
4. Not confirming eradication - test of cure is essential (urea breath test or stool antigen test) 1
5. Using obsolete regimens such as sequential, hybrid, or concomitant therapies 1

Special Populations

• Penicillin allergy: Consider bismuth quadruple therapy or PPI-tetracycline-metronidazole 1
• Children: PPI-amoxicillin-clarithromycin or PPI-amoxicillin-metronidazole or bismuth-amoxicillin-metronidazole 1

Confirmation of Eradication

• Perform test of cure at least 4 weeks after completion of therapy
• Recommended tests: Urea breath test or monoclonal stool antigen test 1
• Avoid serology for confirmation of eradication 1

The management of H. pylori has evolved significantly due to increasing antibiotic resistance. Viewing H. pylori infection as an infectious disease rather than a gastroenterological condition is critical for successful eradication, with the goal being to achieve cure rates of ≥90% 1.