What is the management of Helicobacter pylori (H. pylori) infection?

From the Guidelines

H. pylori infection should be treated with a combination of antibiotics and acid-suppressing medication for 10-14 days, with the preferred first-line regimen being quadruple therapy consisting of a proton pump inhibitor (PPI), bismuth, tetracycline, and metronidazole, as recommended by the most recent guidelines 1. The management of H. pylori infection involves several treatment regimens, including:

• Bismuth quad therapy: bismuth 300mg four times daily, metronidazole 500mg three times daily, tetracycline 500mg four times daily, and PPI twice daily for 14 days
• Concomitant therapy: clarithromycin 500mg twice daily, amoxicillin 1g twice daily, metronidazole 500mg twice daily, and PPI twice daily for 14 days
• Clarithromycin triple therapy: clarithromycin 500mg twice daily, amoxicillin 1g twice daily, and PPI twice daily for 14 days
• Levofloxacin triple therapy: levofloxacin 500mg daily, amoxicillin 1g twice daily, and PPI twice daily for 14 days Treatment success should be confirmed with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and after stopping PPI for at least 2 weeks 1. It is essential to note that antibiotic resistance is increasing globally, so treatment failures should prompt culture and sensitivity testing when possible 1. Patients should be advised to take medications as prescribed, avoid alcohol during treatment (especially with metronidazole), and report side effects like diarrhea or rash. Eradication of H. pylori is crucial because the bacterium causes chronic gastritis, peptic ulcers, and is associated with gastric cancer and MALT lymphoma, making acid suppression an essential component of treatment 1.

From the FDA Drug Label

Adult Patients only Helicobacter pylori Infection and Duodenal Ulcer Disease: Triple therapy for Helicobacter pylori (H. pylori) with clarithromycin and lansoprazole : Amoxicillin, in combination with clarithromycin plus lansoprazole as triple therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) to eradicate H. pylori. Dual therapy for H. pylori with lansoprazole : Amoxicillin, in combination with lansoprazole delayed-release capsules as dual therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) who are either allergic or intolerant to clarithromycin or in whom resistance to clarithromycin is known or suspected.

The management of Helicobacter pylori (H. pylori) infection involves:

• Triple therapy: Amoxicillin, clarithromycin, and lansoprazole to eradicate H. pylori in patients with H. pylori infection and duodenal ulcer disease.
• Dual therapy: Amoxicillin and lansoprazole for patients who are allergic or intolerant to clarithromycin or have known or suspected resistance to clarithromycin 2.

From the Research

Management of Helicobacter pylori (H. pylori) Infection

The management of H. pylori infection typically involves antibiotic therapy, with the goal of eradicating the infection and preventing related diseases.

• The choice of treatment regimen depends on various factors, including antibiotic susceptibility, patient tolerance, and local resistance patterns 3.
• Triple therapy regimens, including two antibiotics plus acid suppression, have become a standard therapy for H. pylori eradication, with success rates of about 90% 4.
• Quadruple therapy regimens, which add a fourth drug to the triple therapy regimen, have also been shown to be effective in eradicating H. pylori, with eradication rates of 91-96% 4, 5.

Treatment Regimens

Several treatment regimens have been studied for the management of H. pylori infection, including:

• Proton-pump inhibitor and amoxicillin-based triple therapy containing clarithromycin (PAC) or metronidazole (PAM) 6.
• Bismuth quadruple therapy (BQT) for 14 days, which is the preferred regimen when antibiotic susceptibility is unknown 7.
• Rifabutin triple therapy or potassium-competitive acid blocker dual therapy for 14 days, which is a suitable empiric alternative in patients without penicillin allergy 7.
• "Optimized" BQT for 14 days, which is preferred for treatment-experienced patients with persistent H. pylori infection who have not been treated with optimized BQT previously and for whom antibiotic susceptibility is unknown 7.

Considerations

When managing H. pylori infection, several considerations should be taken into account, including:

• Antibiotic resistance, which can affect the efficacy of treatment 3.
• Patient education regarding potential and expected side-effects and the importance of completing the course of antibiotics 3.
• The need for universal post-treatment test-of-cure to confirm eradication of the infection 7.
• The role of antibiotic susceptibility testing in guiding the choice of initial and salvage treatment 7.