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

H. pylori Management: Current Recommendations

The recommended management for H. pylori infection includes testing with UBT or stool antigen tests followed by triple or quadruple therapy regimens for 14 days, with mandatory post-treatment testing to confirm eradication. 1, 2

Diagnosis of H. pylori

When to Test

• Test patients with:
  • Uninvestigated dyspepsia in high prevalence areas (≥20%) using test-and-treat strategy 1
  • Peptic ulcer disease (active or history) 1
  • Gastric MALT lymphoma 1
  • Severe gastritis with macro/microscopic abnormalities 1
  • Family history of gastric cancer 2

Diagnostic Methods

• Non-invasive tests (preferred for primary care):

  • 13C-urea breath test (UBT) - highest sensitivity and specificity 1
  • Monoclonal stool antigen tests - excellent alternative 1
  • Validated serological tests - useful in specific situations 1

• Invasive tests (require endoscopy):

  • Rapid urease test
  • Histology
  • Culture with antimicrobial susceptibility testing

Treatment Regimens

First-Line Treatment Options

1. Bismuth Quadruple Therapy (preferred when antibiotic susceptibility unknown) 2

   • Bismuth salt + PPI + tetracycline + metronidazole for 14 days

2. Triple Therapy 3

   • Amoxicillin 1g + clarithromycin 500mg + PPI (e.g., lansoprazole 30mg) twice daily for 14 days

3. Dual Therapy 3

   • Amoxicillin 1g + PPI (e.g., lansoprazole 30mg) three times daily for 14 days

Second-Line/Salvage Regimens

• For patients who failed initial therapy:
  • Rifabutin triple therapy for 14 days 2
  • "Optimized" bismuth quadruple therapy if not used previously 2
  • Levofloxacin-based regimens (only with confirmed susceptibility) 2, 4

Special Populations

• Penicillin allergy: Consider bismuth quadruple therapy with metronidazole instead of amoxicillin 5
• Renal impairment: Adjust amoxicillin dosing 3
  • GFR 10-30 mL/min: 500mg or 250mg every 12 hours
  • GFR <10 mL/min: 500mg or 250mg every 24 hours
• When oral therapy not feasible: IV antibiotics may be considered, though evidence is limited 6

Post-Treatment Management

Test of Cure

• Universal post-treatment testing is essential to confirm eradication 2
• Use UBT or stool antigen test at least 4 weeks after completion of therapy 1
• Avoid PPIs for 2 weeks before testing to prevent false negatives

Clinical Pearls and Pitfalls

Key Considerations

• Rising antibiotic resistance: Clarithromycin resistance rates exceed acceptable thresholds in many regions, limiting its empiric use 4
• Treatment duration: 14-day regimens show superior eradication rates compared to shorter courses 2
• PPI dosing: Higher doses improve eradication rates 1

Common Pitfalls

• Failure to test for cure after treatment
• Using clarithromycin-based regimens in areas with high resistance
• Inadequate treatment duration (less than 14 days)
• Not considering prior antibiotic exposure when selecting regimens

Emerging Concepts

• Antibiotic susceptibility testing: Increasingly important for guiding therapy choices 7
• Population-level screening: May be beneficial in high-risk populations to prevent gastric cancer 7
• Personalized eradication regimens: Based on molecular susceptibility profiling 7

H. pylori management continues to evolve with increasing antibiotic resistance driving changes in recommended first-line therapies. The focus has shifted toward longer treatment durations, bismuth-containing regimens, and confirmation of eradication to reduce morbidity and mortality from peptic ulcer disease and gastric cancer.