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

Treatment of 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 and ability to overcome antibiotic resistance. 1

First-Line Treatment Options

Preferred First-Line Regimen

• Bismuth quadruple therapy (14 days) 1, 2
  • Proton pump inhibitor (PPI)
  • Bismuth subsalicylate
  • Tetracycline (preferred over doxycycline due to higher efficacy)
  • Metronidazole
  • Expected eradication rate: approximately 85%

Alternative First-Line Options

1. Concomitant non-bismuth quadruple therapy (14 days) 1, 3

   • PPI
   • Clarithromycin
   • Amoxicillin
   • Metronidazole
   • Expected eradication rate: approximately 80%
   • Caution: May cause neuropsychiatric symptom exacerbation due to clarithromycin

2. Triple therapy (14 days) 1, 4

   • PPI or lansoprazole
   • Clarithromycin
   • Amoxicillin
   • Expected eradication rate: approximately 85%
   • Note: Should only be used in areas with low clarithromycin resistance (<15%) 3

Treatment Selection Based on Antibiotic Resistance

• In areas with high clarithromycin resistance (≥15%): Use bismuth quadruple therapy or concomitant therapy 3
• In areas with low clarithromycin resistance (<15%): Triple therapy or bismuth quadruple therapy may be used 3

Second-Line Treatment Options

If first-line treatment fails, consider:

1. Levofloxacin-based triple therapy (10-14 days) 3, 5

   • PPI
   • Levofloxacin
   • Amoxicillin
   • Expected eradication rate: approximately 81%

2. Bismuth quadruple therapy (14 days) - if not used as first-line 3, 2

Special Populations

Penicillin Allergy

• Consider penicillin allergy testing for patients without history of anaphylaxis to potentially enable amoxicillin-containing regimens 1
• Use bismuth quadruple therapy with tetracycline and metronidazole 6

Patients with Treatment Failure

• For multiple treatment failures, antimicrobial susceptibility testing is recommended 3, 2
• If testing is unavailable, use antibiotics not previously used or those with low resistance probability (amoxicillin, tetracycline, bismuth, or furazolidone) 3

Treatment Confirmation and Follow-up

• Confirm eradication at least 4 weeks after treatment completion 1
• Use urea breath test (UBT, sensitivity 95%, specificity 90%) or laboratory-based validated monoclonal stool antigen test 1
• For uncomplicated duodenal ulcers, prolonged PPI therapy is not required after successful eradication 1
• For complicated duodenal ulcers or gastric ulcers, continue PPI until eradication is confirmed and complete healing is achieved 1

Patient Management During Treatment

• Advise patients to take medications with meals to improve tolerance and efficacy 1
• Monitor for common side effects: darkening of stool, metallic taste, nausea, diarrhea, vomiting, dizziness, skin rash, and muscle/joint pains 1
• Consider probiotics as adjuvant therapy to reduce side effects and potentially enhance eradication rates, though evidence is limited 1, 7

Special Considerations

• Patients over 45 years with severe symptoms or those with alarm symptoms (anemia, weight loss, dysphagia, palpable mass, malabsorption) should be referred for endoscopy before treatment 1
• For patients with bleeding ulcers, start treatment when oral feeding is resumed 1