Exact Dosing Treatment for H. pylori Infection
The recommended first-line treatment for H. pylori infection is 14-day bismuth quadruple therapy consisting of a proton pump inhibitor (PPI) twice daily, bismuth 300mg four times daily, tetracycline 500mg four times daily, and metronidazole 500mg three times daily. 1
First-Line Treatment Options
Bismuth Quadruple Therapy (Preferred)
- Duration: 14 days
- Components:
- PPI (standard dose) twice daily
- Bismuth subsalicylate 300mg four times daily
- Tetracycline 500mg four times daily
- Metronidazole 500mg three times daily
- Eradication rate: Approximately 85%
- Advantages: Effective in areas with high clarithromycin resistance
Clarithromycin Triple Therapy (For areas with low clarithromycin resistance <15%)
- Duration: 14 days
- Components:
- PPI (high-dose) twice daily
- Clarithromycin 500mg twice daily
- Amoxicillin 1g twice daily
- Eradication rate: Approximately 85% when used in appropriate populations
Concomitant Non-Bismuth Quadruple Therapy
- Duration: 14 days
- Components:
- PPI (standard dose) twice daily
- Clarithromycin 500mg twice daily
- Amoxicillin 1g twice daily
- Metronidazole 500mg twice daily
- Eradication rate: Approximately 80%
PPI Dosing Considerations
High-dose PPI increases the efficacy of triple therapy by 6-10% compared to standard doses 2. Standard PPI doses are:
- Omeprazole 20mg
- Lansoprazole 30mg
- Pantoprazole 40mg
- Esomeprazole 20mg
- Rabeprazole 20mg
- Dexlansoprazole 30mg
For optimal results, double these doses (e.g., esomeprazole 40mg twice daily) and administer 30 minutes before meals 2.
Second-Line Treatment Options
After failure of clarithromycin-containing therapy, use either:
Bismuth Quadruple Therapy
- Same dosing as first-line if not previously used
Levofloxacin Triple Therapy
- Duration: 14 days
- Components:
- PPI (high-dose) twice daily
- Levofloxacin 500mg once daily
- Amoxicillin 1g twice daily
Special Considerations
For Penicillin Allergy
- Consider penicillin allergy testing to potentially enable use of amoxicillin-containing regimens 2
- If true penicillin allergy exists, substitute metronidazole for amoxicillin in triple therapy
For Renal Impairment
- For GFR 10-30 mL/min: Amoxicillin 500mg or 250mg every 12 hours
- For GFR <10 mL/min: Amoxicillin 500mg or 250mg every 24 hours
- For hemodialysis patients: Additional dose during and at end of dialysis 3
Administration Tips
- Take medications with meals to minimize gastrointestinal intolerance 3
- Metronidazole should be taken in divided doses with food to improve tolerance 2
- Avoid alcohol during treatment due to disulfiram-like reaction with metronidazole
- Probiotics may help reduce side effects, though evidence is limited 1
Confirmation of Eradication
- Perform urea breath test or monoclonal stool antigen test at least 4 weeks after completion of therapy 1
- Patients should discontinue PPIs at least 2 weeks before testing
- Antibiotics should be stopped at least 4 weeks before testing
Common Pitfalls to Avoid
Inadequate treatment duration: 14-day regimens are superior to 7-day regimens, providing approximately 5% better eradication rates 2
Suboptimal PPI dosing: Use high-dose, twice-daily PPI to increase efficacy 2
Repeating failed antibiotics: Do not reuse clarithromycin or levofloxacin after treatment failure 2
Ignoring regional resistance patterns: In areas with high clarithromycin resistance (>15-20%), avoid clarithromycin-based regimens 2
Poor patient adherence: Educate patients about potential side effects and the importance of completing the full course of treatment
By following these evidence-based recommendations, H. pylori eradication rates can be optimized, reducing the risk of peptic ulcer disease recurrence and potential progression to gastric cancer.