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

Recommended Treatment for Helicobacter pylori Infection

Bismuth quadruple therapy should be used as first-line treatment for H. pylori infection, especially in areas with high clarithromycin resistance (>15-20%). 1

First-Line Treatment Options

Preferred Regimen:

• Bismuth quadruple therapy for 14 days 1
  • Bismuth salt
  • Proton pump inhibitor (PPI) - high dose, twice daily
  • Tetracycline
  • Metronidazole or amoxicillin

Alternative First-Line Options:

1. In areas with low clarithromycin resistance (<15%):

   • PPI-clarithromycin-amoxicillin (PCA) or
   • PPI-clarithromycin-metronidazole (PCM) 1
   • Duration: 10-14 days (extending from 7 to 10-14 days improves eradication by ~5%) 1

2. Non-bismuth quadruple therapy (concomitant therapy):

   • PPI + clarithromycin + amoxicillin + metronidazole taken simultaneously 1
   • Recommended when bismuth is not available in high-resistance areas

Important Treatment Considerations

• PPI dosing: Use high-dose (twice daily) PPI to increase efficacy 1
• Duration: 14-day regimens are preferred over 7-day regimens 1
• For H. pylori with amoxicillin: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 2
• Dual therapy option: 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days 2

Second-Line Treatment Options

After failure of first-line therapy:

• If first-line was clarithromycin-based: Use bismuth quadruple therapy 1
• If first-line was bismuth quadruple: Use levofloxacin-containing triple therapy 1, 3
  • Levofloxacin (500 mg twice daily)
  • Amoxicillin (1 g twice daily)
  • PPI (standard dose twice daily)
  • Duration: 10-14 days

Third-Line Treatment

• After two treatment failures: Treatment should be guided by antimicrobial susceptibility testing 1
• Empiric third-line option: Levofloxacin-based therapy (if not used previously) 3
• Other options: Rifabutin-based triple therapy or high-dose dual amoxicillin-PPI therapy 1

Antibiotic Resistance Considerations

• Clarithromycin resistance has increased globally from 9% in 1998 to 17.6% in 2008-2009 1
• Avoid reusing antibiotics that were used in failed previous treatment attempts 1
• Rising levofloxacin resistance should be considered when selecting second-line therapy 1

Confirmation of Eradication

• Urea breath test or laboratory-based validated monoclonal stool test are recommended to confirm eradication 1
• Testing should be performed 4-8 weeks after completion of therapy 3

Common Pitfalls to Avoid

1. Using clarithromycin-based triple therapy in high-resistance areas - This approach should be abandoned when clarithromycin resistance exceeds 15-20% 1

2. Inadequate PPI dosing - Always use high-dose (twice daily) PPI to increase efficacy 1

3. Short treatment duration - 7-day regimens have lower success rates; prefer 10-14 day regimens 1

4. Reusing failed antibiotics - Avoid using clarithromycin, levofloxacin, or metronidazole in subsequent regimens if they were used in a failed previous attempt 1

5. Ignoring local resistance patterns - Treatment selection should consider regional antibiotic resistance data whenever possible 1