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

Recommended Treatment for Helicobacter pylori Infection

In areas with high clarithromycin resistance (>15-20%), bismuth-containing quadruple therapy is strongly recommended as first-line treatment for H. pylori infection, while standard triple therapy should be reserved for areas with low clarithromycin resistance. 1

First-Line Treatment Options

For Areas with High Clarithromycin Resistance (>15-20%):

1. Bismuth Quadruple Therapy (14 days) 2, 1
   • PPI (standard dose) twice daily
   • Bismuth subsalicylate/subcitrate 300mg four times daily
   • Tetracycline 500mg four times daily
   • Metronidazole 500mg three times daily

For Areas with Low Clarithromycin Resistance (<15%):

1. Standard Triple Therapy (14 days) 2, 1, 3

   • PPI (standard dose) twice daily
   • Clarithromycin 500mg twice daily
   • Amoxicillin 1000mg twice daily

2. Alternative Triple Therapy 3

   • PPI (standard dose) twice daily
   • Clarithromycin 500mg twice daily
   • Metronidazole 500mg twice daily

Optimization Strategies for Better Eradication Rates

• Duration: All regimens should be given for 14 days rather than 7 or 10 days (improves eradication by approximately 5%) 2, 1, 4
• PPI dosing: Use high-dose (twice daily) PPI to increase efficacy by 6-10% 2, 1
• Timing: Take PPI 30 minutes before meals on an empty stomach 1
• Consider probiotics: May help reduce side effects, though evidence is limited 2

Second-Line Treatment Options

After failure of first-line therapy, the following options are recommended:

1. If clarithromycin-based triple therapy failed:

   • Bismuth quadruple therapy for 14 days 2, 1
   • OR Levofloxacin-based triple therapy for 14 days 2, 1:
     • PPI (standard dose) twice daily
     • Levofloxacin 500mg once daily or 250mg twice daily
     • Amoxicillin 1000mg twice daily

2. If bismuth quadruple therapy failed:

   • Levofloxacin-based triple therapy for 14 days 2, 1

Salvage Therapy (After Multiple Treatment Failures)

• Rifabutin-based triple therapy (10-14 days) 2, 1, 5:

  • PPI (standard dose) twice daily
  • Rifabutin 150-300mg daily
  • Amoxicillin 1000mg twice daily

• After two treatment failures: Antimicrobial susceptibility testing should guide further treatment choices 2, 1, 5

Special Considerations

For Patients with Penicillin Allergy:

• In areas of low clarithromycin resistance: PPI + clarithromycin + metronidazole 2, 6
• In areas of high clarithromycin resistance: Bismuth quadruple therapy with tetracycline instead of amoxicillin 2, 6

For Treatment Verification:

• Urea breath test or monoclonal stool antigen test should be performed at least 4 weeks after completion of therapy to confirm eradication 2
• PPIs should be discontinued at least 2 weeks before testing

Common Pitfalls to Avoid

1. Using clarithromycin-based therapy in high-resistance areas: This leads to treatment failure rates >30% 2, 1

2. Short treatment duration: 7-day regimens have significantly lower eradication rates than 14-day regimens 1, 4

3. Retreating with the same antibiotics after failure: Particularly clarithromycin, which should not be reused after treatment failure 2, 1

4. Inadequate PPI dosing: Using once-daily PPI instead of twice-daily reduces efficacy 2, 1

5. Not confirming eradication: All patients should undergo testing to confirm successful eradication 2, 5

The treatment landscape for H. pylori continues to evolve with increasing antibiotic resistance. Knowing local resistance patterns is crucial for selecting the most appropriate first-line therapy, and all regimens should now be administered for 14 days to maximize eradication success.