What is the standard treatment regimen for H. Pylori (Helicobacter Pylori) infection?

Standard 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)

• Components:
  • Proton pump inhibitor (PPI): Esomeprazole 20-40 mg twice daily
  • Bismuth subsalicylate: 2 tablets (262 mg each) four times daily
  • Tetracycline: 500 mg four times daily
  • Metronidazole: 500 mg three to four times daily
• Duration: 14 days
• Eradication rate: Approximately 85%
• Key administration details:
  • PPIs should be taken 30 minutes before meals
  • Bismuth should be taken 30 minutes before meals
  • Antibiotics should be taken 30 minutes after meals

Alternative First-Line Options

• Triple therapy (in areas with low clarithromycin resistance):

  • Amoxicillin 1 gram twice daily
  • Clarithromycin 500 mg twice daily
  • PPI (e.g., lansoprazole 30 mg) twice daily
  • Duration: 14 days 2

• Dual therapy (for patients allergic/intolerant to clarithromycin or with suspected resistance):

  • Amoxicillin 1 gram three times daily
  • PPI (e.g., lansoprazole 30 mg) three times daily
  • Duration: 14 days 2

Second-Line Treatment Options

If first-line treatment fails, consider:

• Levofloxacin-based therapy: Especially if the patient has previous exposure to metronidazole 1
• High-dose dual therapy: After failure of clarithromycin-based and bismuth quadruple therapies 1
• Rifabutin-containing therapy: Reserved for patients who have failed multiple treatment attempts 1, 3

Treatment Monitoring and Confirmation

• Confirm eradication 4 weeks after completing treatment using:
  • Urea breath test (preferred, 95% sensitivity, 90% specificity)
  • Monoclonal stool antigen test
• Stop PPI 2 weeks before testing to avoid false negatives 1

Special Considerations

Penicillin Allergy

• Bismuth quadruple therapy is the preferred first-line treatment for patients with true penicillin allergy 1

Treatment Failures

• Avoid re-using antibiotics that failed previously, particularly clarithromycin and levofloxacin 1
• For persistent infection after optimized bismuth quadruple therapy, rifabutin triple therapy for 14 days is recommended 3

Medication Selection Tips

• Not all PPIs are equivalent - esomeprazole 20 mg is equivalent to 32 mg of omeprazole, while pantoprazole 40 mg is only equivalent to 9 mg of omeprazole 1
• Separate PPI (before meals) from antibiotics (after meals) to maximize efficacy 1

Common Pitfalls to Avoid

• Using shorter courses (7-10 days) instead of the recommended 14 days reduces eradication rates 1
• Not considering local resistance patterns, especially in areas with high clarithromycin resistance 1, 4
• Failing to confirm eradication after treatment completion 1
• Not stopping PPI before confirmation testing (can lead to false negatives) 1

For patients with gastric ulcers, endoscopy should be performed approximately 6 weeks after discharge to confirm healing and exclude malignancy, with continued PPI therapy until follow-up endoscopy 1.