Recommended Treatment for H. pylori Infection
The recommended first-line treatment for H. pylori infection is either a 14-day bismuth quadruple therapy or a 14-day concomitant non-bismuth quadruple therapy, with bismuth quadruple therapy being preferred when antibiotic susceptibility is unknown. 1, 2
First-Line Treatment Options
Bismuth Quadruple Therapy (Preferred)
- Regimen: PPI (twice daily) + bismuth subsalicylate (300mg four times daily) + tetracycline (500mg four times daily) + metronidazole (500mg three times daily)
- Duration: 14 days
- Eradication rate: Approximately 85% 1
- Best for: Areas with high clarithromycin resistance (>15-20%) or when antibiotic susceptibility is unknown
Concomitant Non-Bismuth Quadruple Therapy
- Regimen: PPI (twice daily) + amoxicillin (1g twice daily) + metronidazole (500mg three times daily) + clarithromycin (500mg twice daily)
- Duration: 14 days
- Eradication rate: Approximately 80% 1
Standard Triple Therapy
- Regimen: PPI (twice daily) + amoxicillin (1g twice daily) + clarithromycin (500mg twice daily)
- Duration: 14 days
- Eradication rate: Approximately 85% 1, 3
- Restriction: Only recommended in areas with known low clarithromycin resistance or high documented eradication success
For Penicillin Allergy
- Use bismuth quadruple therapy as described above 1
Second-Line (Rescue) Treatment Options
If first-line treatment fails:
- Levofloxacin-based regimen: PPI (twice daily) + bismuth (300mg four times daily) + levofloxacin (500mg once daily) + tetracycline (500mg four times daily) for 14 days 1
- Avoid repeating clarithromycin-based regimens if the first treatment contained clarithromycin
Third-Line Treatment Options
- Consider rifabutin-based regimens, but restrict to patients who have failed at least 3 prior options 4, 2
- Antibiotic susceptibility testing is strongly recommended before third-line therapy 5
Important Clinical Considerations
Treatment Duration
- All H. pylori eradication regimens should be given for 14 days to maximize eradication rates 1, 4
- 14-day regimens provide approximately 5% better eradication rates compared to 7-day regimens 1
PPI Dosing
- High-dose PPI increases the efficacy of triple therapy by 6-10% compared to standard doses 1
- Standard PPI doses: omeprazole 20mg, lansoprazole 30mg, pantoprazole 40mg, esomeprazole 20mg, rabeprazole 20mg, dexlansoprazole 30mg
Administration
- Medications should be taken at the start of a meal to minimize gastrointestinal intolerance 3
Confirmation of Eradication
- Confirm eradication at least 4 weeks after completion of treatment 1
- Use urea breath test (UBT) or laboratory-based validated monoclonal stool antigen test
- Ensure patient has been off PPI for at least 2 weeks before testing
Special Considerations
- Renal impairment: For GFR 10-30 mL/min, adjust amoxicillin to 500mg or 250mg every 12 hours; for GFR <10 mL/min, adjust to 500mg or 250mg every 24 hours 1, 3
- Bleeding ulcers: Start treatment when oral feeding is resumed 1
Patient Education
- Inform patients about potential side effects: darkening of stool, metallic taste, nausea, diarrhea, skin rash, vomiting, muscle and joint pains 1
- Emphasize the importance of completing the full 14-day course of treatment to maximize eradication success
- Advise taking the regimen with meals to improve tolerance and efficacy
Common Pitfalls to Avoid
- Using clarithromycin-based regimens in areas with high clarithromycin resistance (>15-20%)
- Prescribing treatment for less than 14 days
- Failing to confirm eradication after treatment
- Not adjusting dosing for patients with renal impairment
- Repeating failed antibiotic regimens without susceptibility testing
The increasing prevalence of antibiotic resistance has significantly reduced the efficacy of traditional triple therapy in many regions, making bismuth quadruple therapy or concomitant quadruple therapy the preferred first-line options for H. pylori eradication 4, 6, 2.