What is the recommended treatment for H pylori (Helicobacter pylori) infection?

Recommended Treatment for H. pylori Infection

For H. pylori eradication, a 14-day bismuth quadruple therapy or concomitant non-bismuth quadruple therapy is strongly recommended as first-line treatment due to increasing antibiotic resistance. 1, 2

First-Line Treatment Options

Preferred Regimens (14-day duration)

1. Bismuth Quadruple Therapy

   • 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% 1

2. Concomitant Non-Bismuth Quadruple Therapy

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

3. Standard Triple Therapy (only in areas with low clarithromycin resistance <15%)

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

For Penicillin Allergy

• Use bismuth quadruple therapy as described above 1

Second-Line (Rescue) Treatment Options

If first-line treatment fails, consider:

• Levofloxacin-Based Regimen (14 days)

  • PPI twice daily
  • Bismuth 300mg four times daily
  • Levofloxacin 500mg once daily
  • Tetracycline 500mg four times daily 1, 3

• Rifabutin-Based Regimen (should be restricted to patients who have failed at least 3 prior options) 3, 2

Important Clinical Considerations

Duration of Treatment

• All H. pylori eradication regimens should now be given for 14 days due to increasing failure rates with shorter durations 1, 3
• 14-day regimens provide approximately 5% better eradication rates compared to 7-day regimens 1

Antibiotic Resistance

• In areas with high clarithromycin resistance (>15-20%), avoid clarithromycin-based regimens 1
• Amoxicillin resistance is rare, making it a reliable component of most regimens 4

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 1

Confirmation of Eradication

• Test for 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

Special Populations

• For patients with renal impairment (GFR 10-30 mL/min), adjust amoxicillin dosing to 500mg or 250mg every 12 hours 1
• For GFR <10 mL/min, adjust amoxicillin dosing to 500mg or 250mg every 24 hours 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 course of treatment 1
• Advise taking medications with meals to improve tolerance and efficacy 1

Common Pitfalls to Avoid

1. Using clarithromycin-based therapy in high-resistance areas - Check local resistance patterns before prescribing
2. Insufficient treatment duration - Always use 14-day regimens for better eradication rates
3. Inadequate PPI dosing - Use high-dose PPI to improve efficacy
4. Failure to confirm eradication - Always test for eradication after treatment
5. Not accounting for previous treatment failures - Choose different antibiotics for rescue therapy based on previous exposure

By following these evidence-based recommendations, clinicians can optimize H. pylori eradication rates and improve patient outcomes.