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

Recommended Treatment for Helicobacter pylori Infection

Bismuth quadruple therapy for 14 days is the recommended first-line treatment for H. pylori infection, especially in areas with high clarithromycin resistance (>15-20%). 1

First-line Treatment Options

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

1. Preferred regimen: Bismuth quadruple therapy for 14 days 1

   • Bismuth salt
   • Proton pump inhibitor (PPI) - high dose, twice daily
   • Tetracycline
   • Metronidazole or amoxicillin

2. Alternative if bismuth unavailable: Non-bismuth quadruple (concomitant) therapy 1

   • PPI (high dose, twice daily)
   • Clarithromycin
   • Amoxicillin
   • Metronidazole

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

1. Clarithromycin triple therapy for 10-14 days 1

   • PPI (high dose, twice daily)
   • Clarithromycin
   • Amoxicillin or metronidazole

2. FDA-approved regimens 2

   • Triple therapy: 1g amoxicillin + 500mg clarithromycin + 30mg lansoprazole, all twice daily for 14 days
   • Dual therapy: 1g amoxicillin + 30mg lansoprazole, each three times daily for 14 days (for clarithromycin-allergic patients)

Important Treatment Considerations

• PPI dosing: High-dose (twice daily) PPI significantly increases eradication success by 6-10% 1
• Treatment duration: Extending treatment from 7 to 10-14 days improves eradication rates by approximately 5% 1
• Antibiotic resistance: Local resistance patterns should guide therapy selection 1
• Compliance: Patient adherence is crucial for successful eradication

Second-line Treatment Options

If first-line therapy fails, the following options are recommended:

1. Bismuth quadruple therapy (if not used initially) 1
2. Levofloxacin-containing triple therapy 1, 3
   • PPI
   • Levofloxacin
   • Amoxicillin
   • Note: Rising levofloxacin resistance should be considered 1

Third-line Treatment

After two treatment failures, therapy should be guided by antimicrobial susceptibility testing whenever possible 1. Options include:

1. Rifabutin-based triple therapy 1
2. High-dose dual amoxicillin-PPI therapy 1
3. Levofloxacin-based rescue therapy (if not previously used) 3

Confirmation of Eradication

Eradication should be confirmed 4-8 weeks after completion of therapy using either:

• Urea breath test
• Validated monoclonal stool antigen test 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. Reusing previously failed antibiotics - Antibiotics used in failed regimens should be avoided in subsequent attempts due to likely resistance 1

3. Inadequate PPI dosing - Using standard rather than high-dose PPI reduces efficacy 1

4. Short treatment duration - 7-day regimens have lower success rates than 10-14 day regimens 1

5. Not confirming eradication - All patients should undergo post-treatment testing to confirm successful eradication 1

The increasing resistance of H. pylori to antibiotics necessitates a strategic approach to treatment selection based on local resistance patterns and previous treatment history. When possible, susceptibility testing should guide therapy selection, especially after treatment failure.