H. pylori Treatment Recommendations
Bismuth quadruple therapy for 14 days is the recommended first-line treatment for H. pylori infection due to increasing worldwide clarithromycin resistance. 1
First-Line Treatment Options
Preferred Regimen (High Clarithromycin Resistance Areas >15-20%)
- Bismuth Quadruple Therapy (14 days):
- Proton pump inhibitor (PPI): standard dose twice daily
- Bismuth subsalicylate/subcitrate: 300mg four times daily
- Tetracycline: 500mg four times daily
- Metronidazole: 500mg three times daily 1
Alternative Regimen (Low Clarithromycin Resistance Areas)
- Standard Triple Therapy (14 days):
- PPI: standard dose twice daily
- Clarithromycin: 500mg twice daily
- Amoxicillin: 1000mg twice daily 1
Alternative First-Line Option
- Concomitant Quadruple Therapy without Bismuth (14 days):
Second-Line Treatment (After Initial Failure)
- Levofloxacin-Based Therapy (14 days):
Third-Line Treatment (After Two Failures)
- Antibiotic susceptibility testing is recommended to guide subsequent regimen selection 1
- Rifabutin Triple Therapy (10 days):
Important Administration Guidelines
Treatment Duration: All regimens should be administered for 14 days to increase eradication rates by approximately 5% 1
PPI Administration:
- Use high-dose (twice daily) PPI to increase efficacy by 6-10%
- Take PPI 30 minutes before meals on an empty stomach 1
Confirmation of Eradication:
- Perform breath test with urea or monoclonal fecal antigen test at least 4 weeks after completing treatment
- Discontinue PPIs at least 2 weeks before testing 1
Key Considerations and Pitfalls
Never reuse the same antibiotic after treatment failure, particularly clarithromycin 1
Common Pitfalls:
- Inadequate PPI dosing (once-daily instead of twice-daily)
- Insufficient treatment duration (less than 14 days)
- Failure to confirm eradication 1
Clinical Importance: Eradication of H. pylori is crucial to prevent progression of chronic gastritis and reduce risk of complications such as peptic ulcer and gastric cancer 1
FDA-Approved Indication: Amoxicillin is specifically indicated for H. pylori infection in adults as part of combination therapy with clarithromycin and lansoprazole (triple therapy) or with lansoprazole alone (dual therapy) in patients allergic or intolerant to clarithromycin 4
The American College of Gastroenterology's 2024 guideline reinforces bismuth quadruple therapy for 14 days as the preferred regimen when antibiotic susceptibility is unknown 3, aligning with the recommendations from the American Gastroenterological Association 1.