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

Recommended Treatment for Helicobacter pylori Infection

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

First-Line Treatment Options

Bismuth Quadruple Therapy (Preferred)

• Regimen components:
  • Proton pump inhibitor (PPI) twice daily
  • Bismuth subcitrate/subsalicylate 120-240mg four times daily
  • Tetracycline 500mg four times daily
  • Metronidazole 500mg three to four times daily
• Duration: 14 days
• Eradication rate: Approximately 85% 1
• Rationale: Overcomes antibiotic resistance, achieves high eradication rates, and promotes antibiotic stewardship by avoiding overuse of clarithromycin 1

Alternative First-Line Options

1. Concomitant non-bismuth quadruple therapy

   • 14-day duration with 80% eradication rate
   • Caution advised due to potential neuropsychiatric symptom exacerbation with clarithromycin-containing regimens 1

2. Triple therapy for specific situations

   • For H. pylori with duodenal ulcer: Amoxicillin 1g, clarithromycin 500mg, and lansoprazole 30mg, all twice daily for 14 days 2
   • Alternative dual therapy (for clarithromycin allergy/resistance): Amoxicillin 1g and lansoprazole 30mg, each three times daily for 14 days 2

Treatment Selection Algorithm

1. First choice: Bismuth quadruple therapy for 14 days 1, 3
2. If penicillin allergy is present: Consider penicillin allergy testing to potentially enable use of amoxicillin-containing regimens 1
3. If bismuth quadruple therapy fails: Consider rifabutin triple therapy for 14 days 3
4. For clarithromycin or levofloxacin-containing regimens: Only use if antibiotic susceptibility is confirmed 3

Post-Treatment Management

• Confirm eradication at least 4 weeks after treatment completion using:
  • Urea breath test (preferred, 95% sensitivity, 90% specificity)
  • Laboratory-based validated monoclonal stool antigen test 1
• For uncomplicated duodenal ulcers: No prolonged PPI needed after successful eradication 1
• For complicated duodenal ulcers or gastric ulcers: Continue PPI until eradication is confirmed and complete healing is achieved 1

Patient Education and Side Effect Management

• Take medications with meals to improve tolerance and efficacy
• Common side effects include:
  • Darkening of stool
  • Metallic taste
  • Nausea and vomiting
  • Diarrhea
  • Dizziness
  • Skin rash
  • Muscle and joint pains 1

Special Considerations

• Patients >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
• Patients with bleeding ulcers should start treatment when oral feeding is resumed 1

Common Pitfalls to Avoid

1. Using clarithromycin-containing triple therapy as empiric first-line treatment - Increasing antimicrobial resistance has led to unacceptable eradication rates 4, 3
2. Inadequate treatment duration - 14-day regimens are recommended for optimal eradication rates 1, 3
3. Failure to confirm eradication - Always perform test of cure at least 4 weeks after treatment completion 1, 3
4. Not considering antibiotic resistance patterns - When available, susceptibility testing should guide therapy selection 3
5. Overlooking patient adherence factors - Complex regimens with frequent dosing and side effects may reduce compliance

The landscape of H. pylori treatment continues to evolve due to increasing antibiotic resistance. While bismuth quadruple therapy currently offers the best empiric approach, susceptibility-guided treatment represents the ideal approach when feasible 4.