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

Recommended Treatment for Helicobacter pylori Infection

The American College of Gastroenterology recommends a 14-day bismuth quadruple therapy or standard triple therapy as first-line regimens for H. pylori eradication, with bismuth quadruple therapy being preferred in areas with high clarithromycin resistance (>15-20%). 1

First-Line Treatment Options

Standard Triple Therapy (14 days)

• Proton pump inhibitor (PPI) twice daily
• Amoxicillin 1g twice daily
• Clarithromycin 500mg twice daily
• Expected eradication rate: 85% 1

Bismuth Quadruple Therapy (14 days)

• PPI twice daily
• Bismuth 300mg four times daily
• Tetracycline 500mg four times daily
• Metronidazole 500mg three times daily
• Expected eradication rate: 85% 1
• Recommended for patients with amoxicillin allergy 1

Alternative First-Line Option

• Concomitant non-bismuth quadruple therapy (14 days)
• Expected eradication rate: 80% 1

Treatment Selection Considerations

When to Use Bismuth Quadruple Therapy

• Areas with high clarithromycin resistance (>15-20%)
• Patients with penicillin/amoxicillin allergy
• Previous macrolide exposure

When to Use Standard Triple Therapy

• Areas with low clarithromycin resistance (<15%)
• No previous macrolide exposure

Second-Line Treatment

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

Important Treatment Considerations

PPI Dosing

• High-dose PPI increases triple therapy efficacy by 6-10% 1
• Standard PPI doses:
  • Omeprazole 20mg
  • Lansoprazole 30mg
  • Pantoprazole 40mg
  • Esomeprazole 20mg
  • Rabeprazole 20mg
  • Dexlansoprazole 30mg 1

Duration

• 14-day regimens are superior to 7-day regimens, providing approximately 5% better eradication rates 1

Confirmation of Eradication

• Test at least 4 weeks after treatment completion
• Use urea breath test (UBT) or laboratory-based validated monoclonal stool antigen test
• Patient should be off PPI for at least 2 weeks before testing 1

Special Patient Populations

Renal Impairment

• For GFR 10-30 mL/min: Adjust amoxicillin to 500mg or 250mg every 12 hours
• For GFR <10 mL/min: Adjust amoxicillin to 500mg or 250mg every 24 hours 1

Patients with Bleeding Ulcers

• Start treatment when oral feeding is resumed 1

Patient Education

• Inform patients about potential side effects:
  • Darkening of stool (bismuth)
  • Metallic taste
  • Nausea and diarrhea
  • Skin rash, vomiting, muscle and joint pains 1
• Emphasize the importance of completing the full course of treatment 1
• Take medications with meals to improve tolerance and efficacy 1

Clinical Pearls and Pitfalls

Common Pitfalls

1. Inadequate treatment duration: 7-day regimens have lower eradication rates; always use 14-day regimens 1
2. Not confirming eradication: Always confirm eradication at least 4 weeks after treatment 1
3. Testing too soon after PPI use: Ensure patient is off PPI for at least 2 weeks before confirmation testing 1
4. Using clarithromycin in high-resistance areas: In areas with >15-20% clarithromycin resistance, avoid clarithromycin-based regimens 1

Clinical Pearls

• 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
• Endoscopic follow-up is needed to ensure complete healing in gastric ulcers 1