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

H. pylori Treatment Recommendations

In areas with high clarithromycin resistance (>15-20%), bismuth-containing quadruple therapy is recommended as first-line empirical treatment for H. pylori infection; if bismuth is unavailable, sequential or non-bismuth quadruple therapy should be used instead. 1

First-Line Treatment Options

The choice of first-line therapy depends primarily on local clarithromycin resistance rates:

For areas with low clarithromycin resistance (<15%):

• PPI-clarithromycin-containing triple therapy:
  • PPI (high-dose, twice daily)
  • Clarithromycin 500mg twice daily
  • Amoxicillin 1g twice daily OR metronidazole 500mg twice daily
  • Duration: 14 days (extends eradication success by ~5% compared to 7-day regimens) 1

For areas with high clarithromycin resistance (>15-20%):

• Bismuth-containing quadruple therapy (preferred):

  • PPI (twice daily)
  • Bismuth salts
  • Tetracycline HCl
  • Metronidazole
  • Duration: 10-14 days 1

• Non-bismuth quadruple therapy (concomitant) (if bismuth unavailable):

  • PPI
  • Amoxicillin
  • Clarithromycin
  • Metronidazole/tinidazole
  • All medications given simultaneously
  • Duration: 10-14 days 1

• Sequential therapy (if bismuth unavailable):

  • Days 1-5: PPI + amoxicillin
  • Days 6-10: PPI + clarithromycin + metronidazole/tinidazole
  • Duration: 10 days 1

FDA-Approved Regimens

According to the FDA label for amoxicillin 2:

• Triple therapy:

  • Amoxicillin 1g twice daily
  • Clarithromycin 500mg twice daily
  • Lansoprazole 30mg twice daily
  • Duration: 14 days

• Dual therapy (for clarithromycin allergy/resistance):

  • Amoxicillin 1g three times daily
  • Lansoprazole 30mg three times daily
  • Duration: 14 days

Second-Line Treatment

After failure of a PPI-clarithromycin-containing therapy:

• Bismuth-containing quadruple therapy OR
• Levofloxacin-containing triple therapy 1

Note: Rising rates of levofloxacin resistance should be considered when selecting second-line therapy 1

Third-Line Treatment

After failure of second-line treatment:

• Treatment should be guided by antimicrobial susceptibility testing whenever possible 1

Important Considerations

1. High-dose PPI improves efficacy:

   • Use twice-daily dosing of PPI (Level of evidence: 1b, Grade of recommendation: A) 1
   • Second-generation PPIs (esomeprazole, rabeprazole) at higher doses may increase cure rates 1

2. Duration of therapy:

   • 14-day regimens are generally recommended for optimal eradication rates 1

3. Adjuvant therapy:

   • Certain probiotics may help reduce side effects (Level of evidence: 5, Grade of recommendation: D) 1

4. Confirmation of eradication:

   • Urea breath test or validated monoclonal stool test recommended (not serology) 1
   • Testing should be performed at least 4 weeks after completion of therapy

Special Populations

• Penicillin allergy: Consider substituting tetracycline for amoxicillin in regimens 1
• Renal impairment: Adjust amoxicillin dosing for severe renal impairment 2

Common Pitfalls to Avoid

1. Using clarithromycin-based therapy in high-resistance areas - This leads to unacceptably low eradication rates (<70%)

2. Inadequate duration of therapy - Short courses (7 days) have lower success rates

3. Using standard-dose PPI - Higher doses improve eradication rates

4. Not considering previous antibiotic exposure - Prior macrolide use increases risk of clarithromycin resistance

5. Using inappropriate antibiotics - For example, using doxycycline instead of tetracycline HCl, or ciprofloxacin instead of levofloxacin 1

The treatment of H. pylori has become increasingly complex due to rising antibiotic resistance. The most important factor in treatment failure is clarithromycin resistance, which has increased globally from 9% in 1998 to over 20% in many regions 1. This necessitates careful selection of first-line therapy based on local resistance patterns to maximize eradication rates and reduce the risk of treatment failure.