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

Recommended Treatment for Helicobacter pylori Infection

The recommended first-line treatment for H. pylori infection is bismuth quadruple therapy for 14 days, consisting of a proton pump inhibitor (PPI) standard dose twice daily, bismuth subsalicylate 300mg four times daily, tetracycline 500mg four times daily, and metronidazole 500mg three times daily. 1

First-Line Treatment Options

Treatment selection should be based on local clarithromycin resistance patterns:

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

1. Preferred: Bismuth quadruple therapy (14 days)

   • PPI (standard dose) twice daily
   • Bismuth subsalicylate/subcitrate 300mg four times daily
   • Tetracycline 500mg four times daily
   • Metronidazole 500mg three times daily 1

2. Alternative: Non-bismuth quadruple therapy (concomitant) (14 days)

   • PPI (standard dose) twice daily
   • Amoxicillin 1000mg twice daily
   • Metronidazole 500mg three times daily
   • Clarithromycin 500mg twice daily 1

Low Clarithromycin Resistance Areas:

• Standard triple therapy (14 days)
  • PPI (standard dose) twice daily
  • Clarithromycin 500mg twice daily
  • Amoxicillin 1000mg twice daily 1, 2

Important Administration Considerations

• PPI should be taken 30 minutes before meals on an empty stomach to maximize efficacy 1
• High-dose (twice daily) PPI increases efficacy by 6-10% 1
• Amoxicillin should be taken at the start of a meal to minimize gastrointestinal intolerance 2
• All regimens should be administered for 14 days to increase eradication rates by approximately 5% 1, 3

Second-Line Treatment Options (After First-Line Failure)

After failure of first-line therapy, options include:

1. Bismuth quadruple therapy (if not used as first-line)
2. Levofloxacin-based triple therapy (14 days)
   • PPI (standard dose) twice daily
   • Levofloxacin 500mg once daily or 250mg twice daily
   • Amoxicillin 1000mg twice daily 1

Important: Avoid retreating with the same antibiotics after failure, particularly clarithromycin 1

Third-Line Treatment Options

After two failed therapies:

• Consider H. pylori susceptibility testing to guide subsequent regimen selection 1
• Rifabutin triple therapy (10 days)
  • PPI standard dose twice daily
  • Rifabutin 150mg or 300mg daily
  • Amoxicillin 1000mg twice daily 1

Confirmation of Eradication

• Perform a urea breath test or fecal antigen monoclonal test at least 4 weeks after completing treatment 1
• Discontinue PPIs at least 2 weeks before testing to avoid false negatives 1

Common Pitfalls to Avoid

1. Inadequate PPI dosing: Using once-daily PPI instead of twice-daily reduces efficacy 1
2. Insufficient treatment duration: Less than 14 days results in lower eradication rates 1, 3
3. Not confirming eradication: Leads to unnecessary retreatment 1
4. Reusing failed antibiotics: Particularly clarithromycin after failure 1
5. Ignoring antibiotic resistance patterns: Local resistance patterns should guide therapy selection 1, 4

Special Considerations

• In patients with renal impairment (GFR <30 mL/min), avoid the 875mg dose of amoxicillin and adjust dosing according to severity of impairment 2
• For patients with penicillin allergy, alternative regimens may be required
• Probiotics may help reduce side effects, though evidence is limited 1

The American College of Gastroenterology's 2024 guideline confirms bismuth quadruple therapy for 14 days as the preferred regimen when antibiotic susceptibility is unknown 4, aligning with the recommendations from the American Gastroenterological Association and European Helicobacter Study Group 1.