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

Recommended Dosing for H. pylori Treatment

The recommended first-line treatment for H. pylori infection is a 14-day regimen consisting of either bismuth quadruple therapy or concomitant non-bismuth quadruple therapy, with specific dosing based on regional clarithromycin resistance patterns. 1, 2

First-Line Treatment Options

In areas with low clarithromycin resistance (<15%):

• PPI-clarithromycin-amoxicillin (PCA) triple therapy:
  • PPI (standard dose) twice daily
  • Amoxicillin 1000 mg twice daily
  • Clarithromycin 500 mg twice daily
  • Duration: 14 days 1, 2

In areas with high clarithromycin resistance (≥15%):

• Bismuth quadruple therapy (PBMT):

  • PPI (standard dose) twice daily
  • Bismuth subsalicylate 300 mg four times daily
  • Metronidazole 500 mg three to four times daily
  • Tetracycline 500 mg four times daily
  • Duration: 14 days 1, 2

• Concomitant non-bismuth quadruple therapy (PAMC):

  • PPI (standard dose) twice daily
  • Amoxicillin 1000 mg twice daily
  • Metronidazole 500 mg twice daily
  • Clarithromycin 500 mg twice daily
  • Duration: 14 days 1, 2

Key Dosing Considerations

• PPI dosing: High-dose PPI increases eradication rates by 6-10% compared to standard doses 1

  • Standard PPI doses: omeprazole 20 mg, lansoprazole 30 mg, pantoprazole 40 mg, esomeprazole 20 mg, rabeprazole 20 mg, dexlansoprazole 30 mg
  • High-dose: double the standard dose

• Treatment duration: 14-day regimens are superior to 7-day regimens, providing approximately 5% better eradication rates 1, 2

• Administration timing: Take medications at the start of meals to minimize gastrointestinal intolerance 3

Second-Line Treatment Options

If first-line treatment fails:

• Levofloxacin-based therapy:

  • PPI (standard dose) twice daily
  • Amoxicillin 1000 mg twice daily
  • Levofloxacin 500 mg once daily or 250 mg twice daily
  • Duration: 14 days 1

• Bismuth quadruple therapy (if not used as first-line)

Special Populations

For patients with penicillin allergy:

• Use bismuth quadruple therapy (PBMT) as first-line 1, 2

For patients with renal impairment:

• GFR 10-30 mL/min: Amoxicillin 500 mg or 250 mg every 12 hours
• GFR <10 mL/min: Amoxicillin 500 mg or 250 mg every 24 hours 3

Treatment Verification

• Confirm eradication at least 4 weeks after completion of treatment
• Use urea breath test or monoclonal stool antigen test
• Ensure patient has been off PPI for at least 2 weeks before testing 1, 2

Common Pitfalls to Avoid

1. Inadequate treatment duration: 7-day regimens have significantly lower eradication rates compared to 14-day regimens 1, 2

2. Using clarithromycin in high-resistance areas: In regions with clarithromycin resistance >15-20%, avoid clarithromycin-based regimens as first-line therapy 1, 2

3. Insufficient acid suppression: Using standard-dose PPI instead of high-dose can reduce eradication rates by 6-10% 1

4. Re-using failed antibiotics: Avoid re-using clarithromycin or levofloxacin if they failed in previous treatment attempts 1

5. Inadequate patient education: Failure to emphasize the importance of completing the full course of treatment can lead to treatment failure and antibiotic resistance 2

The evidence strongly supports 14-day regimens over shorter durations, with selection of specific antibiotics based on local resistance patterns. High-dose PPI therapy further improves eradication rates by enhancing the efficacy of the antibiotic components.