What's the treatment for Helicobacter pylori (H. pylori) infection?

Treatment 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, consisting of a proton pump inhibitor (PPI), bismuth subsalicylate/subcitrate, tetracycline, and metronidazole. 1, 2

First-Line Treatment Options

Preferred First-Line Therapy

• Bismuth quadruple therapy (14 days):
  • PPI (standard dose) twice daily
  • Bismuth subsalicylate/subcitrate
  • Tetracycline 500mg four times daily
  • Metronidazole 500mg three to four times daily
  • Achieves eradication rates >80% 1

Alternative First-Line Options

1. In areas with low clarithromycin resistance (<20%):

   • Standard triple therapy: PPI (standard dose) twice daily + clarithromycin 500mg twice daily + amoxicillin 1000mg twice daily for 14 days 3, 1

2. When bismuth is unavailable:

   • Non-bismuth quadruple therapy: PPI twice daily + amoxicillin 1000mg twice daily + metronidazole 500mg twice daily + clarithromycin 500mg twice daily for 14 days 1

3. For penicillin allergy:

   • Bismuth-containing quadruple therapy (as above) 3, 1

Optimizing Treatment Success

• Use higher-potency PPIs like esomeprazole or rabeprazole at 40mg twice daily rather than lower-potency options 1
• Take PPIs 30 minutes before meals on an empty stomach 1
• 14-day treatment duration increases eradication rates by approximately 5% compared to shorter regimens 1
• Antimicrobial stewardship considerations: Amoxicillin, tetracycline, and metronidazole have lower resistance potential (WHO "Access group") compared to clarithromycin and levofloxacin (WHO "Watch group") 3

Second-Line Treatment (After First-Line Failure)

1. 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

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

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

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

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

Third-Line Treatment (After Two Treatment Failures)

• Antimicrobial susceptibility testing should guide therapy whenever possible 3, 1
• Avoid reusing previously failed antibiotics, particularly clarithromycin 1

Confirming Eradication

• Test for eradication at least 4 weeks after completing treatment 1
• Preferred testing methods:
  • Urea breath test (UBT)
  • Monoclonal stool antigen test 3, 1
• Discontinue PPIs at least 2 weeks before testing to avoid false-negative results 1

Special Considerations

• For bleeding ulcers: Start H. pylori eradication treatment at reintroduction of oral feeding 3
• For gastric ulcers: Continue PPI treatment after eradication therapy until complete healing is achieved 3
• For duodenal ulcers: Continue PPI until H. pylori eradication is confirmed, particularly for complicated cases 3

Common Pitfalls to Avoid

1. Using clarithromycin-based regimens in areas with high clarithromycin resistance (>20%) 3
2. Testing for eradication too soon (before 4 weeks post-treatment) 1
3. Not stopping PPIs before testing for eradication (can cause false-negative results) 1
4. Reusing antibiotics that previously failed, particularly clarithromycin 1
5. Using inadequate treatment durations (shorter than 14 days) 1

H. pylori infection is a chronic condition that requires appropriate antibiotic therapy to prevent complications such as peptic ulcer disease and gastric cancer 4, 5. The treatment approach should be guided by local antibiotic resistance patterns whenever possible, with bismuth-containing regimens offering the most reliable empiric therapy in most regions.