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

Treatment Guidelines for H. Pylori Infection

For H. pylori eradication, bismuth quadruple therapy for 14 days is the recommended first-line treatment when antibiotic susceptibility is unknown, with a reported eradication rate of 85%. 1

First-Line Treatment Options

When antibiotic susceptibility is unknown:

• Bismuth quadruple therapy (14 days) - preferred regimen 1, 2
  • Components: Proton pump inhibitor (PPI) + bismuth salt + tetracycline + metronidazole (or amoxicillin)
  • Eradication rate: 85%

Alternative first-line regimens:

• Standard triple therapy (14 days) - only in areas with low clarithromycin resistance (<15%) 1

  • Components: PPI + amoxicillin + clarithromycin
  • Dosing: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily 3
  • Eradication rate: 85% (when used for 14 days)

• Concomitant non-bismuth quadruple therapy (14 days) 1, 4

  • Components: PPI + amoxicillin + clarithromycin + metronidazole
  • Eradication rate: 80%

Important Treatment Considerations

Duration of Therapy

• 14-day regimens are strongly recommended over 10-day or 7-day regimens, providing approximately 5% better eradication rates 1

Acid Suppression

• PPIs should be taken at the start of a meal to minimize gastrointestinal intolerance 3
• Stop PPIs 2 weeks before testing for H. pylori (except for serology) to avoid false negatives 1

Special Populations

• Renal impairment: Patients with GFR <30 mL/min should NOT receive 875 mg amoxicillin doses; adjust dosing according to severity 3
• Pregnancy: Defer treatment until after pregnancy unless severe symptoms or complications are present 1
• Breastfeeding: Most medications used for H. pylori treatment are compatible with breastfeeding 1

Second-Line Treatment Options

If first-line therapy fails, recommended options include:

• Levofloxacin triple therapy (14 days) 1, 5

  • Components: PPI + amoxicillin + levofloxacin
  • Use only if bismuth quadruple therapy was used first-line

• Bismuth quadruple therapy (14 days) 1

  • Use if not previously used as first-line treatment

Follow-up and Confirmation of Eradication

• Confirmation of H. pylori eradication should be performed 4 weeks after completing treatment 1
• Use urea breath test (sensitivity 95%, specificity 90%) or monoclonal stool antigen test 1
• Ensure patient has been off PPI for at least 2 weeks before testing 1

Treatment Failures and Salvage Therapy

• For patients with multiple treatment failures, antimicrobial susceptibility testing should be performed 4
• If susceptibility testing is unavailable, use antibiotics not previously used or for which resistance is unlikely (amoxicillin, tetracycline, bismuth, or furazolidone) 4
• Rifabutin triple therapy is a suitable empiric alternative for treatment-experienced patients 2

Indications for Testing and Treatment

H. pylori testing and treatment is recommended for:

• Patients with 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, idiopathic thrombocytopenic purpura, or vitamin B12 deficiency 4

Referral Criteria

• Patients >45 years with severe symptoms or any patient with alarm symptoms (dysphagia, palpable abdominal mass, malabsorption, weight loss, anemia) should be referred for endoscopy before treatment 1
• Younger patients (<45 years) without alarm symptoms can be managed in primary care with H. pylori testing and eradication 1