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

Recommended Treatment Regimen for H. pylori Infection

Bismuth quadruple therapy for 14 days is the recommended first-line treatment for H. pylori infection, especially in areas with high clarithromycin resistance (≥15%). 1

First-Line Treatment Options

Bismuth Quadruple Therapy (Preferred)

• Esomeprazole 20-40 mg twice daily (30 minutes before meals)
• Bismuth subsalicylate 2 tablets (262 mg each) four times daily (30 minutes before meals)
• Tetracycline 500 mg four times daily (30 minutes after meals)
• Metronidazole 500 mg three to four times daily
• Duration: 14 days
• Eradication rate: 85% 1

Alternative Regimens

1. Concomitant non-bismuth quadruple therapy

   • Duration: 14 days
   • Eradication rate: 80% 1

2. Standard triple therapy (only in areas with low clarithromycin resistance <15%)

   • Duration: 14 days
   • Eradication rate: 85% 1

3. Dual therapy (FDA-approved alternative)

   • Amoxicillin 1 gram three times daily
   • Lansoprazole 30 mg three times daily
   • Duration: 14 days 2

Important Administration Guidelines

• PPI (e.g., esomeprazole) should be taken 30 minutes before meals on an empty stomach 1
• Antibiotics should be taken after meals, separated from PPI administration 1
• 14-day treatment duration is strongly recommended for optimal eradication rates 1
• Not all PPIs are equally effective - esomeprazole-based regimens show higher eradication rates (94%) compared to pantoprazole-based regimens (82%) 1

Confirmation of Eradication

• Test for eradication 4 weeks after completing treatment 1
• Use urea breath test or monoclonal stool antigen test 1
• Stop PPI 2 weeks before testing to avoid false negatives 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: Using shorter courses (7-10 days) instead of the recommended 14 days significantly reduces eradication rates 1

2. Improper medication timing: Failing to separate PPI (before meals) from antibiotics (after meals) can reduce efficacy 1

3. Using clarithromycin triple therapy in high-resistance areas: Not recommended in areas with clarithromycin resistance >15% 1

4. Inadequate follow-up: Failure to confirm eradication can lead to persistent infection and complications 1

5. Improper testing for eradication: Testing while still on PPI therapy can lead to false negative results 1

Special Patient Populations

• Patients with gastric ulcers: Endoscopy should be performed approximately 6 weeks after discharge to confirm healing and exclude malignancy 1

• Patients requiring continued NSAID use: Use ibuprofen (least damaging NSAID) with a PPI 1

• Patients with chronic gastritis: Provide vitamin B12 supplementation to prevent pernicious anemia 1

• Patients with risk factors for gastric cancer or atrophic gastritis: Surveillance endoscopy should be performed every 3 years 1

By following these evidence-based recommendations, clinicians can optimize H. pylori eradication rates and improve patient outcomes.