What is the recommended antibiotic regimen for Helicobacter pylori (H. Pylori) eradication?

First-Line Treatment Regimens for H. pylori Eradication

Bismuth quadruple therapy for 14 days is the preferred first-line treatment for H. pylori eradication when antibiotic susceptibility is unknown. 1

First-Line Treatment Options

In Areas with High Clarithromycin Resistance (≥15-20%):

• 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

• Alternative: Concomitant Therapy (14 days):

  • PPI (standard dose) twice daily
  • Clarithromycin 500mg twice daily
  • Amoxicillin 1000mg twice daily
  • Metronidazole 500mg twice daily 2

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

• Triple Therapy (14 days):

  • PPI (standard dose) twice daily
  • Clarithromycin 500mg twice daily
  • Amoxicillin 1000mg twice daily 1, 3

• Alternative: Triple Therapy with Metronidazole:

  • PPI (standard dose) twice daily
  • Clarithromycin 500mg twice daily
  • Metronidazole 500mg twice daily 4

Key Considerations for Optimal Treatment

1. Duration: All regimens should be administered for 14 days to increase eradication rates by approximately 5% 1

2. PPI Dosing:

   • Use higher-potency PPIs (esomeprazole or rabeprazole) at 40mg twice daily
   • Take PPIs 30 minutes before meals on an empty stomach
   • Twice-daily PPI dosing increases efficacy by 6-10% 1

3. Special Populations:

   • Penicillin Allergy: Use bismuth quadruple therapy as first-line treatment 1
   • Consider penicillin allergy testing in patients without history of anaphylaxis to potentially enable use of amoxicillin-containing regimens 1

Second-Line Treatment Options

If first-line treatment fails, choose a regimen that avoids previously used antibiotics:

• Levofloxacin Triple Therapy (14 days):

  • PPI (standard dose) twice daily
  • Levofloxacin 500mg once daily or 250mg twice daily
  • Amoxicillin 1000mg twice daily 1

• Bismuth Quadruple Therapy (14 days) - if not used as first-line treatment 1

Treatment After Multiple Failures

• After two treatment failures, antimicrobial susceptibility testing should guide further treatment whenever possible 1, 5

• Rifabutin Triple Therapy (10-14 days):

  • PPI (standard dose) twice daily
  • Rifabutin 150-300mg daily
  • Amoxicillin 1000mg twice daily 1, 5

Confirmation of Eradication

• Confirm eradication with urea breath test or monoclonal stool antigen test at least 4 weeks after completing treatment 1
• Discontinue PPIs at least 2 weeks before testing to avoid false-negative results 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: Using 7-day regimens instead of 14-day regimens reduces efficacy 1

2. Insufficient acid suppression: Once-daily PPI instead of twice-daily reduces treatment success 1

3. Reusing previously failed antibiotics: Particularly clarithromycin, which has high resistance rates in many regions 1, 4

4. Testing too soon after treatment: Testing for eradication before 4 weeks post-treatment can lead to false results 1

5. Not stopping PPIs before testing: Continuing PPIs within 2 weeks of testing can cause false-negative results 1

The evolution of H. pylori treatment has shifted from clarithromycin-based triple therapy to bismuth quadruple therapy as first-line treatment due to increasing antibiotic resistance worldwide 4, 5. This approach achieves eradication rates over 80% on an intention-to-treat basis, which is the minimum acceptable threshold for effective therapy 4, 1.