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

Treatment for Helicobacter pylori Infection

The recommended first-line treatment for H. pylori infection is bismuth quadruple therapy for 14 days, consisting of a proton pump inhibitor (PPI), bismuth subcitrate, tetracycline, and metronidazole, which achieves an eradication rate of approximately 85%. 1

First-Line Treatment Options

Bismuth Quadruple Therapy (Preferred)

• PPI (standard dose) twice daily
• Bismuth subcitrate ~300mg four times daily
• Tetracycline 500mg four times daily
• Metronidazole 500mg three times daily
• Duration: 14 days 1

Alternative First-Line Regimens

• In areas with low clarithromycin resistance (<15%):
  • Triple therapy: PPI, amoxicillin, and clarithromycin for 14 days 2
• For patients with clarithromycin allergy or high resistance:
  • Concomitant non-bismuth quadruple therapy for 14 days 1, 2

Maximizing Treatment Efficacy

Optimize PPI Dosing

• Use high-dose PPIs (increases eradication rates by 6-10%)
• Administer PPI 30 minutes before meals on an empty stomach
• Consider PPIs not metabolized by CYP2C19 for better efficacy 1

Optimize Antibiotic Dosing

• Amoxicillin: at least 2g daily in 3-4 divided doses
• Metronidazole: 1.5-2g daily in divided doses 1

Second-Line Treatment Options

If first-line treatment fails, choose based on previous therapy:

After Failed Clarithromycin-Based Triple Therapy

• Bismuth quadruple therapy for 14 days 1

After Failed Bismuth Quadruple Therapy

• Levofloxacin-based triple therapy: PPI (standard dose) twice daily, amoxicillin 1000mg twice daily, and levofloxacin 500mg once daily or 250mg twice daily for 14 days
• Rifabutin-based triple therapy with high-dose PPI and amoxicillin 1

Special Populations

Penicillin Allergy

• Use bismuth-based quadruple therapy with tetracycline and metronidazole
• Consider allergy testing for non-anaphylactic penicillin allergy to potentially enable amoxicillin use 1

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 and Adherence

• Clearly explain dosing instructions
• Discuss expected adverse events (darkening of stool, metallic taste, nausea, diarrhea)
• Emphasize importance of completing the full course of treatment 1

Test of Cure and Follow-up

• Confirm eradication at least 4 weeks after treatment completion
• Use urea breath test (95% sensitivity, 90% specificity) or monoclonal stool antigen test
• Ensure patient has been off PPI for at least 2 weeks before testing 1

Common Pitfalls to Avoid

• Reusing failed antibiotics, particularly clarithromycin and levofloxacin
• Inadequate PPI dosing
• Short treatment duration (7-day regimens have lower success rates than 14-day regimens)
• Ignoring prior antibiotic exposure
• Using unproven adjunctive therapies 1

Indications for Treatment

H. pylori eradication is indicated for:

• Active or past history of peptic ulcer
• Chronic dyspepsia
• Chronic NSAID or aspirin use
• Precancerous gastric lesions or gastric cancer
• MALT lymphoma
• Family history of gastric cancer or peptic ulcers
• Iron deficiency anemia
• Vitamin B12 deficiency 2

The FDA has approved amoxicillin for H. pylori infection in combination with clarithromycin plus lansoprazole as triple therapy, or with lansoprazole as dual therapy for patients allergic or intolerant to clarithromycin 3. However, current guidelines favor bismuth quadruple therapy due to increasing clarithromycin resistance 1, 4.