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

Treatment of Helicobacter Pylori Infection

The preferred first-line treatment for H. pylori infection is bismuth quadruple therapy for 14 days when antibiotic susceptibility is unknown, as this regimen provides the highest eradication rates and addresses increasing clarithromycin resistance. 1, 2

Treatment Regimens Based on Regional Resistance Patterns

In Areas of Low Clarithromycin Resistance (<15-20%)

• First-line options:
  • PPI-clarithromycin-amoxicillin triple therapy (10-14 days)
  • Bismuth quadruple therapy (alternative)

In Areas of High Clarithromycin Resistance (>15-20%)

• First-line options:
  • Bismuth quadruple therapy (preferred)
  • Sequential therapy or non-bismuth quadruple therapy (if bismuth unavailable)

Specific Treatment Regimens

Triple Therapy (for areas with low clarithromycin resistance)

• Proton pump inhibitor (PPI) (twice daily)
• Clarithromycin 500 mg (twice daily)
• Amoxicillin 1 gram (twice daily)
• Duration: 10-14 days (extending from 7 to 10-14 days improves eradication by ~5%) 1

Bismuth Quadruple Therapy

• PPI (twice daily)
• Bismuth salt
• Tetracycline
• Metronidazole
• Duration: 14 days

Sequential Therapy

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

Special Populations

Patients with Penicillin Allergy

• In areas of low clarithromycin resistance: PPI + clarithromycin + metronidazole
• In areas of high clarithromycin resistance: Bismuth quadruple therapy 1

Treatment-Experienced Patients

• After failure of clarithromycin-containing therapy: Bismuth quadruple therapy or levofloxacin-containing triple therapy
• After failure of second-line therapy: Treatment guided by antimicrobial susceptibility testing when possible 1

Key Treatment Considerations

1. High-dose PPI: Using twice-daily dosing increases the efficacy of triple therapy 1

2. Antibiotic resistance: Local H. pylori antibiotic resistance patterns should guide treatment selection 1

3. Confirmation of eradication:

   • Urea breath test (UBT) or monoclonal stool test at least 4 weeks after treatment
   • Endoscopy with biopsy for patients with gastric ulcer, MALT lymphoma, or complicated peptic ulcer disease 1

4. Duration of treatment: Minimum of 10-14 days is recommended for all regimens to improve eradication rates 1

Common Pitfalls to Avoid

1. Using clarithromycin-based therapy empirically in high-resistance regions: This leads to treatment failure and further resistance development 1

2. Inadequate duration of therapy: Short courses (7 days) have lower eradication rates 1

3. Testing too soon after treatment: Testing for eradication should be performed at least 4 weeks after completing therapy to avoid false negative results 1

4. Failing to consider antibiotic history: Previous antibiotic exposure increases risk of resistance, particularly for clarithromycin and fluoroquinolones 1, 3

5. Not confirming eradication: Failure to confirm successful treatment can lead to ongoing disease and complications 1

H. pylori eradication is critical as it significantly reduces the risk of peptic ulcer recurrence, gastric cancer, and MALT lymphoma progression. The treatment approach must be adapted to local resistance patterns to achieve optimal outcomes in terms of morbidity, mortality, and quality of life.