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

Recommended Treatment for Helicobacter pylori Infection

Bismuth quadruple therapy for 14 days is the recommended first-line treatment for H. pylori infection due to its high eradication rates (approximately 85%) and ability to overcome antibiotic resistance. 1

First-Line Treatment Options

Preferred First-Line Regimen

• Bismuth quadruple therapy (14 days) 1
  • Proton pump inhibitor (PPI)
  • Bismuth
  • Tetracycline (preferred over doxycycline due to higher efficacy)
  • Metronidazole

Alternative First-Line Options

1. Concomitant non-bismuth quadruple therapy (14 days) 1

   • Eradication rate: approximately 80%
   • Caution: potential for neuropsychiatric symptom exacerbation with clarithromycin-containing regimens

2. Standard triple therapy (14 days) 1, 2

   • PPI + clarithromycin + amoxicillin (or metronidazole)
   • Only recommended in areas with known low clarithromycin resistance
   • FDA approved regimens include:
     • Triple therapy: amoxicillin + clarithromycin + lansoprazole
     • Dual therapy: amoxicillin + lansoprazole (for patients allergic/intolerant to clarithromycin)

Treatment Duration

All H. pylori eradication regimens should be given for 14 days to maximize eradication rates 1, 3. The American Gastroenterological Association specifically recommends 14-day bismuth quadruple therapy when susceptibility testing or regional data are not available.

Post-Treatment Confirmation

• Confirm eradication at least 4 weeks after completing treatment 1
• Preferred testing methods:
  • Urea breath test (UBT) - gold standard with 95% sensitivity, 90% specificity
  • Laboratory-based validated monoclonal stool antigen test

Special Patient Considerations

Patient Age and Symptoms

• 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

Penicillin Allergy

• Consider penicillin allergy testing in patients with history of penicillin allergy but without anaphylaxis 1, 4
• For confirmed penicillin allergies, bismuth quadruple therapy is an excellent option as it doesn't contain amoxicillin 1, 4

Post-Treatment Care

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

Patient Management During Treatment

Side Effect Management

• Common side effects: darkening of stool, metallic taste, nausea, diarrhea, dizziness, vomiting 1
• Advise patients to take medication with meals to improve tolerance and efficacy 1
• Monitor both gastrointestinal and neuropsychiatric symptoms during treatment 1
• Probiotics may help reduce side effects, though evidence is limited 1

Rescue Therapies for Treatment Failure

If first-line therapy fails, consider:

1. Bismuth quadruple therapy (if not used initially) 1, 3
2. Levofloxacin-containing therapy (PPI + amoxicillin + levofloxacin) 3, 5
3. Rifabutin-containing regimens (restricted to patients who have failed at least 3 prior options) 3, 5

Common Pitfalls to Avoid

• Using shorter treatment durations (less than 14 days) 1, 3
• Using standard triple therapy in areas with high clarithromycin resistance 1, 3
• Using doxycycline instead of tetracycline in bismuth quadruple therapy (significantly lower efficacy) 1
• Failing to confirm eradication after treatment 1
• Not considering antibiotic resistance patterns when selecting therapy 1, 5