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

Recommended Treatment for H. Pylori Infection

Bismuth quadruple therapy is recommended as the first-line treatment for H. pylori infection, with a high eradication rate of approximately 85%, and is effective even in areas with high antibiotic resistance. 1

First-Line Treatment Options

Bismuth Quadruple Therapy (Preferred)

• Duration: 14 days
• Eradication rate: 85%
• Effective even in areas with high antibiotic resistance
• Recommended by the European Helicobacter Study Group and Gastroenterology societies 1

Alternative First-Line Options

1. Triple Therapy

   • Components: Proton pump inhibitor (PPI), clarithromycin, and amoxicillin
   • Dosage: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily 2
   • Duration: 14 days
   • Eradication rate: 85% (in areas with low clarithromycin resistance <20%)
   • Note: Declining efficacy due to increasing antimicrobial resistance 3

2. Concomitant Non-Bismuth Quadruple Therapy

   • Duration: 14 days
   • Eradication rate: 80%
   • Caution: Potential for neuropsychiatric symptom exacerbation with clarithromycin-containing regimens 1

Second-Line and Salvage Therapy

If first-line treatment fails, options include:

1. Levofloxacin-Based Regimen

   • Components: Levofloxacin (500 mg twice daily), amoxicillin (1g twice daily), and PPI (20 mg twice daily)
   • Duration: 10 days
   • Eradication rate: 66% as third-line therapy 4
   • Note: Should only be used if antibiotic susceptibility is confirmed 5

2. Rifabutin Triple Therapy

   • Duration: 14 days
   • Recommended for treatment-experienced patients who failed bismuth quadruple therapy 5

Special Considerations

Confirmation of Eradication

• Testing should be performed at least 4 weeks after completion of treatment 1
• Preferred methods:
  • Urea breath test (UBT) - gold standard with 95% sensitivity and 90% specificity
  • Laboratory-based validated monoclonal stool antigen test 1
• Serology is not recommended for post-treatment confirmation 1

Patient-Specific Factors

• 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 with H. pylori testing and eradication 1
• For patients with penicillin allergy, consider penicillin allergy testing to potentially enable the use of amoxicillin-containing regimens 1

Management After Treatment

• In uncomplicated duodenal ulcers, prolonged acid inhibition with PPI is not required after successful H. pylori eradication 1
• In complicated duodenal ulcers, PPI should be continued until H. pylori eradication is confirmed 1
• For gastric ulcers, PPI therapy should be continued until complete healing is achieved 1

Common Side Effects and Management

• Common side effects: diarrhea, skin rash, vomiting, nausea, metallic taste, and muscle/joint pains 1
• Probiotics may help reduce side effects, though evidence is limited 1
• Monitor for both gastrointestinal and neuropsychiatric symptoms during treatment 1

Treatment Pitfalls to Avoid

• Avoid using clarithromycin-containing regimens in areas with high clarithromycin resistance (>20%) 3, 5
• Do not use serology for post-treatment confirmation due to slow decline of antibody levels 1
• Do not start treatment before endoscopy in patients with alarm symptoms 1
• Avoid shortened treatment courses - 14-day regimens are recommended for optimal eradication rates 1, 2, 5
• Do not use levofloxacin or clarithromycin-based salvage regimens without confirming antibiotic susceptibility 5

The landscape of H. pylori treatment is evolving due to increasing antibiotic resistance, making bismuth quadruple therapy the most reliable first-line option in most regions. Treatment should be followed by confirmation of eradication using appropriate testing methods at least 4 weeks after completion of therapy.