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

Recommended Treatment Regimen for Helicobacter pylori Infection

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

First-Line Treatment Options

Preferred First-Line Regimen

• Bismuth quadruple therapy (14 days):
  • PPI (standard dose) twice daily
  • Bismuth subsalicylate/subcitrate
  • Tetracycline
  • Metronidazole
  • Achieves eradication rates >80% 1

Alternative First-Line Regimens

• In areas with low clarithromycin resistance:

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

• For penicillin allergy patients:

  • Bismuth quadruple therapy is recommended 1

• When bismuth is unavailable:

  • PPI twice daily
  • Amoxicillin 1000mg twice daily
  • Metronidazole 500mg twice daily
  • Clarithromycin 500mg twice daily 1

Optimizing Treatment Success

PPI Administration

• Use higher-potency PPIs (esomeprazole or rabeprazole 40mg twice daily) 1
• Take PPIs 30 minutes before meals on an empty stomach 1
• High-dose PPIs increase treatment efficacy by 6-10% 1

Treatment Duration

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

Medication Administration

• Take amoxicillin at the start of a meal to minimize gastrointestinal intolerance 2

Second-Line Treatment Options

After first-line treatment failure, consider:

1. Rifabutin triple therapy (10-14 days):

   • PPI
   • Rifabutin 150mg twice daily or 300mg once daily
   • Amoxicillin 1000mg twice daily 1

2. High-dose dual therapy (14 days):

   • PPI four times daily
   • Amoxicillin 750mg four times daily 1

3. Levofloxacin-containing regimen (10-14 days) (in areas with low fluoroquinolone resistance):

   • PPI
   • Levofloxacin
   • Clarithromycin 1

Confirmation of Eradication

• Eradication should be verified at least 4 weeks after treatment completion 1
• Use urea breath test (UBT) or monoclonal stool antigen test 1
• Discontinue PPIs at least 2 weeks before testing to avoid false-negative results 1

Special Considerations

After Multiple Treatment Failures

• After two treatment failures, antimicrobial susceptibility testing should guide further treatment whenever possible 1
• Avoid reusing previously failed antibiotics, particularly clarithromycin 1

Penicillin Allergy

• Consider penicillin allergy testing in patients with a history of penicillin allergy but without anaphylaxis 1
• This may allow the use of amoxicillin-containing regimens if the patient is not truly allergic 1

Renal Impairment

• For patients with severe renal impairment (GFR 10-30 mL/min): 500mg or 250mg amoxicillin every 12 hours 2
• For patients with GFR <10 mL/min: 500mg or 250mg amoxicillin every 24 hours 2
• Patients on hemodialysis: administer an additional dose both during and at the end of dialysis 2

Common Pitfalls to Avoid

1. Testing too soon after treatment (before 4 weeks) can lead to false results 1
2. Not stopping PPIs before testing can cause false-negative results 1
3. Using clarithromycin in areas with high resistance rates or after previous treatment failure 1
4. Inadequate treatment duration - shorter courses have lower eradication rates 1
5. Using standard-dose PPIs instead of high-dose, which reduces efficacy 1
6. Not considering antimicrobial susceptibility testing after multiple treatment failures 1