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

Treatment of Helicobacter pylori Infection

Bismuth quadruple therapy for 14 days is the preferred first-line treatment for H. pylori infection when antibiotic susceptibility is unknown. 1

First-Line Treatment Options

The treatment landscape for H. pylori has evolved significantly due to increasing antibiotic resistance, particularly to clarithromycin. Current guidelines recommend:

Preferred First-Line Therapy:

• Bismuth quadruple therapy (14 days) 1, 2
  • PPI (twice daily)
  • Bismuth subsalicylate/subcitrate
  • Tetracycline (500 mg four times daily)
  • Metronidazole (500 mg three or four times daily)

Alternative First-Line Options (when bismuth is unavailable):

• Non-bismuth quadruple/concomitant therapy (10-14 days) 1
  • PPI (twice daily)
  • Amoxicillin (1000 mg twice daily)
  • Clarithromycin (500 mg twice daily)
  • Metronidazole (500 mg twice daily)

Important Considerations:

• Standard triple therapy (PPI, clarithromycin, amoxicillin) should be abandoned in regions with clarithromycin resistance rates >15-20% 1
• High-dose PPI (twice daily) significantly increases treatment efficacy 1
• 14-day treatment duration is preferred over shorter courses 1

Second-Line Treatment Options

After failure of first-line therapy, treatment should be guided by the following principles:

• Never reuse antibiotics that were previously unsuccessful (especially clarithromycin) 1

• After failure of clarithromycin-containing therapy:

  • Bismuth quadruple therapy (if not used initially)
  • Levofloxacin-containing triple therapy 1

• After failure of bismuth quadruple therapy:

  • Levofloxacin triple therapy
  • Rifabutin-based triple therapy 1

Third-Line and Salvage Therapy

For patients who have failed multiple treatment attempts:

• Antibiotic susceptibility testing is strongly recommended whenever possible 1
• Rifabutin-based triple therapy (14 days) 1, 2
• High-dose dual amoxicillin-PPI therapy 1

Special Considerations

Antibiotic Resistance

• Clarithromycin resistance is the primary cause of treatment failure and has increased from 9% (1998) to >20% in many regions 1
• Metronidazole resistance can often be overcome by increasing dose and duration 3
• Levofloxacin resistance is increasing and should be considered before prescribing 1

Verification of Eradication

• Confirm eradication 4-6 weeks after treatment 3
• Use urea breath test or monoclonal stool antigen test (not serology) 1

Adjunctive Therapies

• Some probiotics may help reduce treatment side effects, though evidence is limited 1

Common Pitfalls to Avoid

1. Using clarithromycin-based therapy in high-resistance regions - This leads to unacceptably low eradication rates
2. Short treatment durations - 7-day regimens have lower success rates than 14-day regimens
3. Not confirming eradication - All patients should undergo post-treatment testing
4. Reusing failed antibiotics - Previously used antibiotics should be avoided in subsequent attempts
5. Standard-dose PPI - Using high-dose PPI significantly improves eradication rates

Treatment Algorithm

1. First-line: Bismuth quadruple therapy for 14 days
2. If bismuth unavailable: Non-bismuth quadruple/concomitant therapy for 14 days
3. Second-line: Choose therapy that doesn't include previously used antibiotics
4. Third-line: Base treatment on susceptibility testing when possible

The increasing prevalence of antibiotic resistance makes H. pylori treatment increasingly challenging, requiring careful selection of regimens based on local resistance patterns and previous treatment history.