What is the recommended triple therapy regimen for Helicobacter pylori (H. pylori) treatment?

Recommended Triple Therapy Regimens for H. pylori Eradication

Bismuth quadruple therapy for 14 days is the preferred first-line treatment regimen for H. pylori eradication when antibiotic susceptibility is unknown. 1, 2, 3

First-Line Treatment Options

Preferred Regimen: 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 to four times daily 1, 2

Alternative First-Line Option: Concomitant Non-Bismuth Quadruple Therapy (14 days)

When bismuth is unavailable:

• PPI (standard dose) twice daily
• Amoxicillin 1000mg twice daily
• Metronidazole 500mg twice daily
• Clarithromycin 500mg twice daily 1, 2

Traditional Triple Therapy (NOT RECOMMENDED as first-line)

Due to increasing clarithromycin resistance worldwide, the traditional triple therapy is no longer recommended as first-line treatment unless local clarithromycin resistance is known to be low (<15-20%) 1, 2:

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

Important Treatment Considerations

Duration of Therapy

• All regimens should be administered for 14 days to increase eradication rates by approximately 5% 1, 2

PPI Dosing

• Higher-potency PPIs (esomeprazole or rabeprazole) at 40mg twice daily are more effective
• PPIs should be taken 30 minutes before meals on an empty stomach 2

Special Circumstances

• For penicillin allergy: Bismuth quadruple therapy is recommended 2
• For dual therapy (FDA approved): Amoxicillin 1g and lansoprazole 30mg, each given three times daily for 14 days 4

Second-Line Treatment Options

If first-line treatment fails, avoid previously used antibiotics, particularly clarithromycin. Options include:

1. Levofloxacin Triple Therapy (14 days):

   • PPI (standard dose) twice daily
   • Levofloxacin 500mg once daily or 250mg twice daily
   • Amoxicillin 1000mg twice daily 2, 5

2. Bismuth Quadruple Therapy (14 days, if not used as first-line):

   • Same regimen as first-line bismuth quadruple therapy 2

Third-Line Treatment Options

After two treatment failures:

1. Antibiotic Susceptibility Testing:

   • Should guide further treatment whenever possible 2, 3

2. Rifabutin Triple Therapy (10-14 days):

   • PPI (standard dose) twice daily
   • Rifabutin 150mg twice daily or 300mg once daily
   • Amoxicillin 1000mg twice daily 1, 2

3. High-Dose Dual Therapy (14 days):

   • PPI (high dose) four times daily
   • Amoxicillin 750mg four times daily 1, 2

Confirmation of Eradication

• Test for eradication at least 4 weeks after completing treatment
• Use urea breath test or monoclonal stool antigen test
• Discontinue PPIs at least 2 weeks before testing 2

Common Pitfalls to Avoid

1. Using clarithromycin-based triple therapy in areas with high clarithromycin resistance
2. Insufficient treatment duration (less than 14 days)
3. Reusing previously failed antibiotics in subsequent treatment attempts
4. Inadequate PPI dosing (once-daily instead of twice-daily)
5. Testing for eradication too soon after treatment completion
6. Not stopping PPIs before testing for eradication

The shift from clarithromycin-based triple therapy to bismuth quadruple therapy as first-line treatment reflects the global increase in antibiotic resistance, particularly to clarithromycin. This approach maximizes the chance of successful eradication on the first attempt, reducing the need for retreatment and minimizing the development of further antibiotic resistance.