Recommended Treatment for Helicobacter pylori Infection
The recommended first-line treatment for H. pylori infection is either a 14-day bismuth quadruple therapy (PPI + bismuth + tetracycline + metronidazole) or a 14-day concomitant non-bismuth quadruple therapy (PPI + amoxicillin + metronidazole + clarithromycin), both of which provide approximately 85% eradication rates. 1
First-Line Treatment Options
Bismuth Quadruple Therapy
- PPI twice daily
- Bismuth 300mg four times daily
- Tetracycline 500mg four times daily
- Metronidazole 500mg three times daily
- Duration: 14 days 1
Concomitant Non-Bismuth Quadruple Therapy
- PPI twice daily
- Amoxicillin 1g twice daily
- Metronidazole 500mg three times daily
- Clarithromycin 500mg twice daily
- Duration: 14 days 1
Standard Triple Therapy (restricted use)
- Only use in areas with known low clarithromycin resistance (<15-20%)
- PPI twice daily
- Amoxicillin 1g twice daily
- Clarithromycin 500mg twice daily
- Duration: 14 days 1, 2
Alternative for Penicillin Allergy
For patients with amoxicillin allergy, bismuth quadruple therapy is the recommended regimen 1:
- PPI twice daily
- Bismuth 300mg four times daily
- Tetracycline 500mg four times daily
- Metronidazole 500mg three times daily
- Duration: 14 days
Second-Line (Rescue) Therapy
If first-line treatment fails, consider:
- Levofloxacin-based regimen: PPI twice daily, bismuth 300mg four times daily, levofloxacin 500mg once daily, and tetracycline 500mg four times daily for 14 days 1
- Alternative bismuth quadruple therapy (if not used as first-line)
Important Clinical Considerations
Duration of Treatment
All H. pylori eradication regimens should be given for 14 days, as 14-day regimens are superior to 7-day regimens, providing approximately 5% better eradication rates 1, 3.
Confirmation of Eradication
- Confirm eradication at least 4 weeks after completion of treatment
- 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 1
Dosing in Renal Impairment
For patients with renal impairment 2:
- GFR 10-30 mL/min: Adjust amoxicillin to 500mg or 250mg every 12 hours
- GFR <10 mL/min: Adjust amoxicillin to 500mg or 250mg every 24 hours
- Patients with GFR <30 mL/min should NOT receive the 875mg dose of amoxicillin
Patient Education
- Take medications with meals to minimize gastrointestinal intolerance 2
- Inform patients about potential side effects: darkening of stool, metallic taste, nausea, diarrhea, skin rash 1
- Emphasize the importance of completing the full course of treatment
Special Considerations
- In areas with high clarithromycin resistance (>15-20%), avoid clarithromycin-based regimens 1
- High-dose PPI increases the efficacy of triple therapy by 6-10% compared to standard doses 1
- For patients with bleeding ulcers, start treatment when oral feeding is resumed 1
- For uncomplicated duodenal ulcer, prolonged PPI therapy is not required after successful H. pylori eradication 1
- For complicated duodenal ulcer, continue PPI until H. pylori eradication is confirmed 1
The treatment of H. pylori has evolved due to increasing antibiotic resistance, making the traditional triple therapy less effective in many regions. The quadruple therapies now play a more prominent role in eradication and should be given for a full 14 days to maximize success rates.