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

H. pylori Treatment Recommendations

The preferred treatment for H. pylori infection is a 14-day bismuth quadruple therapy regimen containing a proton pump inhibitor, bismuth subsalicylate, tetracycline, and metronidazole, which has an eradication rate of 85%. 1

First-Line Treatment Options

Preferred Regimen

• Bismuth Quadruple Therapy (14 days):
  • Proton pump inhibitor (PPI)
  • Bismuth subsalicylate
  • Tetracycline
  • Metronidazole
  • Eradication rate: 85% 1

Alternative Regimens

1. Concomitant Non-Bismuth Quadruple Therapy (14 days):

   • PPI
   • Amoxicillin
   • Metronidazole
   • Clarithromycin
   • Eradication rate: 80% 1

2. Standard Triple Therapy (14 days):

   • PPI
   • Clarithromycin
   • Amoxicillin
   • Eradication rate: 85% (only recommended in areas with low clarithromycin resistance <20%) 1

3. Dual Therapy for H. pylori:

   • 1 gram amoxicillin three times daily
   • 30 mg lansoprazole three times daily
   • Duration: 14 days 2

Treatment Administration

• Medications should be taken at the start of a meal to minimize gastrointestinal intolerance 2
• All H. pylori eradication regimens should now be given for 14 days due to increasing treatment failure with shorter durations 1, 3
• For triple therapy specifically, the FDA-approved dosing is 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 2

Testing Before and After Treatment

• Before initiating treatment:

  • Stop PPIs for at least 2 weeks to avoid false-negative results
  • Use urea breath test or monoclonal antibody-based stool antigen test for diagnosis (sensitivity 95%, specificity 90%) 1
  • If PPIs cannot be stopped, validated IgG serology can be performed 1

• After treatment:

  • Perform follow-up test at least 4 weeks after completion of treatment
  • Use urea breath test or monoclonal stool antigen test (sensitivity 90%, specificity 95%) 1

Management of Treatment Failure

• If first-line therapy fails, use a different regimen than the initial treatment 1
• After two treatment failures, obtain antimicrobial susceptibility testing to guide further treatment 1
• For treatment-experienced patients with persistent H. pylori infection, "optimized" bismuth quadruple therapy for 14 days is preferred for those who have not been treated with optimized bismuth quadruple therapy previously 1, 3
• Levofloxacin-based therapy can be considered as a rescue treatment 1, 4
• Rifabutin regimens should be restricted to patients who have failed to respond to at least 3 prior options 3

Special Considerations

Patient Referral

• Patients over 45 years with severe symptoms or any patients with alarm symptoms (anemia, weight loss, dysphagia, palpable mass, malabsorption) should be referred for endoscopy before treatment 1
• Younger patients (<45 years) without alarm symptoms can be managed in primary care 1

Ulcer Management

• For gastric ulcers, PPI therapy should be continued until complete healing is achieved 1
• For duodenal ulcers, PPI therapy should be continued until bacterial eradication is confirmed 1
• Patients with bleeding ulcers should start treatment when oral feeding is resumed 1

Antibiotic Resistance

• In areas with high clarithromycin resistance, bismuth-containing quadruple therapy is the preferred first-line treatment 1, 5
• Antibiotic resistance is a major cause of treatment failure, with clarithromycin resistance being particularly problematic 5, 6

Penicillin Allergy

• Consider penicillin allergy testing in patients with a history of penicillin allergy but without anaphylaxis, to potentially enable the use of amoxicillin-containing regimens 1
• For patients with confirmed penicillin allergy, bismuth quadruple therapy is a suitable alternative as it does not contain amoxicillin 7

Common Pitfalls and Caveats

• Inadequate treatment duration: Ensure full 14-day treatment course to maximize eradication rates 1, 3
• Ignoring antibiotic resistance patterns: Consider local resistance patterns when selecting therapy 1, 5
• Poor patient compliance: Educate patients about the importance of completing the full course of treatment despite potential side effects 6
• Failure to confirm eradication: Always perform post-treatment testing to confirm successful eradication 1
• Common side effects include diarrhea, skin rash, vomiting, nausea, metallic taste, and muscle and joint pains 1
• Renal impairment: Patients with severe renal impairment (GFR <30 mL/min) should NOT receive the 875 mg dose of amoxicillin 2