What is the recommended treatment for H pylori infection?

Recommended Treatment for H. pylori Infection

The recommended first-line treatment for H. pylori infection is a 14-day regimen of either bismuth quadruple therapy or standard triple therapy, depending on local clarithromycin resistance patterns. 1

First-Line Treatment Options

In Areas with High Clarithromycin Resistance (≥15%)

1. Bismuth Quadruple Therapy (14 days) 1

   • Proton pump inhibitor (PPI) twice daily
   • Bismuth 300mg four times daily
   • Tetracycline 500mg four times daily
   • Metronidazole 500mg three times daily
   • Eradication rate: approximately 85%

2. Concomitant Non-Bismuth Quadruple Therapy (14 days) 1, 2

   • PPI twice daily
   • Amoxicillin 1g twice daily
   • Metronidazole 500mg three times daily
   • Clarithromycin 500mg twice daily
   • Eradication rate: approximately 80%

In Areas with Low Clarithromycin Resistance (<15%)

1. Standard Triple Therapy (14 days) 1, 3

   • PPI twice daily
   • Amoxicillin 1g twice daily
   • Clarithromycin 500mg twice daily
   • Eradication rate: approximately 85%

2. For Penicillin Allergy 1

   • Use bismuth quadruple therapy as described above

Second-Line Treatment Options

If first-line treatment fails, consider:

1. Levofloxacin-Based Regimen (14 days) 1, 4

   • PPI twice daily
   • Bismuth 300mg four times daily
   • Levofloxacin 500mg once daily
   • Tetracycline 500mg four times daily

2. Bismuth Quadruple Therapy (if not used as first-line) 1, 2

Special Considerations

H. pylori Eradication for Duodenal Ulcer Disease

• Triple therapy: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 3
• Dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days 3

Dosage Adjustment for Renal Impairment

• For GFR 10-30 mL/min: Amoxicillin 500mg or 250mg every 12 hours 1, 3
• For GFR <10 mL/min: Amoxicillin 500mg or 250mg every 24 hours 3

Treatment Duration

• 14-day regimens are superior to 7-day regimens, providing approximately 5% better eradication rates 1, 4
• High-dose PPI increases the efficacy of triple therapy by 6-10% compared to standard doses 1

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 1
• Ensure patient has been off PPI for at least 2 weeks before testing 1

Patient Education

• Take medications with meals to improve tolerance and efficacy 1
• Complete the full course of treatment to ensure successful eradication 1
• Be aware of potential side effects:
  • Darkening of stool (bismuth)
  • Metallic taste
  • Nausea and diarrhea
  • Skin rash
  • Muscle and joint pains 1

Common Pitfalls to Avoid

1. Using clarithromycin-based regimens in areas with high resistance - In areas with clarithromycin resistance >15-20%, avoid clarithromycin-based regimens 1, 2

2. Insufficient treatment duration - 7-day regimens have lower eradication rates; 14-day regimens are now strongly recommended 1, 4

3. Failure to confirm eradication - Always confirm eradication to ensure treatment success 1

4. Inadequate acid suppression - Use high-dose PPI to increase efficacy 1

5. Not considering previous treatment history - Previous treatments significantly affect eradication success rates 5