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

Treatment for H. pylori Infection

The first-line treatment for H. pylori infection is a 14-day bismuth quadruple therapy consisting of a proton pump inhibitor (PPI) twice daily, bismuth 300mg four times daily, tetracycline 500mg four times daily, and metronidazole 500mg three times daily, which provides an eradication rate of approximately 85%. 1

First-Line Treatment Options

Standard Triple Therapy (for areas with low clarithromycin resistance)

• PPI twice daily
• Amoxicillin 1g twice daily
• Clarithromycin 500mg twice daily
• Duration: 14 days 1

Bismuth Quadruple Therapy (preferred when antibiotic susceptibility is unknown)

• PPI twice daily
• Bismuth 300mg four times daily
• Tetracycline 500mg four times daily
• Metronidazole 500mg three times daily
• Duration: 14 days 1, 2

For Penicillin Allergy

• Use bismuth quadruple therapy as described above 1

Treatment Duration and Efficacy

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

Alternative Regimens

• Concomitant non-bismuth quadruple therapy (14 days): 80% eradication rate 1
• For areas with high clarithromycin resistance (>15-20%), avoid clarithromycin-based regimens 1
• Levofloxacin-based regimen for treatment failures: PPI twice daily, bismuth 300mg four times daily, levofloxacin 500mg once daily, and tetracycline 500mg four times daily for 14 days 1, 3

Post-Treatment Follow-up

• 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
• 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

Special Considerations

• 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
• Patients with bleeding ulcers should start treatment when oral feeding is resumed 1

Patient Education

• Inform patients about potential side effects:
  • Darkening of stool (from bismuth)
  • Metallic taste
  • Nausea and vomiting
  • Diarrhea
  • Skin rash
  • 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 shorter 7-day regimens instead of the more effective 14-day regimens
2. Failing to confirm eradication after treatment
3. Using clarithromycin-based regimens in areas with high resistance
4. Not adjusting medication doses for patients with renal impairment
5. Inadequate patient education about the importance of completing the full treatment course

The American College of Gastroenterology's 2024 guidelines strongly recommend bismuth quadruple therapy as the preferred regimen when antibiotic susceptibility is unknown, which is consistent with the American Gastroenterological Association's recommendations 1, 2.