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

H. pylori Eradication Therapy Recommendations

The recommended first-line treatment for H. pylori infection is a 14-day course of bismuth quadruple therapy (BQT), consisting of a proton pump inhibitor (PPI) twice daily, bismuth subsalicylate/subcitrate 120-300 mg four times daily, tetracycline 500 mg four times daily, and metronidazole 500 mg three to four times daily. 1

Treatment Selection Based on Clarithromycin Resistance

Treatment selection should be guided by local clarithromycin resistance patterns:

Areas with High Clarithromycin Resistance (≥15%):

• First-line options:
  • 14-day bismuth quadruple therapy (BQT)
  • 14-day concomitant non-bismuth quadruple therapy (PPI + amoxicillin + metronidazole + clarithromycin) 2

Areas with Low Clarithromycin Resistance (<15%):

• First-line options:
  • 14-day bismuth quadruple therapy (BQT)
  • 14-day triple therapy (PPI + clarithromycin + amoxicillin) 2

Specific Treatment Regimens

Bismuth Quadruple Therapy (BQT)

• PPI twice daily
• Bismuth subsalicylate/subcitrate 120-300 mg four times daily
• Tetracycline 500 mg four times daily
• Metronidazole 500 mg three to four times daily
• Duration: 14 days
• Expected eradication rate: 85% 1

Triple Therapy

• PPI twice daily
• Clarithromycin 500 mg twice daily
• Amoxicillin 1000 mg twice daily
• Duration: 14 days
• Expected eradication rate: 85% (in areas with low clarithromycin resistance) 1

Dual Therapy (FDA-approved)

• Amoxicillin 1 gram three times daily
• Lansoprazole 30 mg three times daily
• Duration: 14 days 3

Second-Line Treatment Options

If first-line therapy fails, consider:

1. Levofloxacin-based therapy:

   • PPI twice daily
   • Amoxicillin 1000 mg twice daily
   • Levofloxacin 500 mg once daily
   • Duration: 14 days 1

2. Bismuth quadruple therapy (if not used as first-line) 1

3. Rifabutin triple therapy (after multiple treatment failures):

   • PPI twice daily
   • Rifabutin 150 mg twice daily
   • Amoxicillin 1000 mg twice daily
   • Duration: 14 days 1

Special Considerations

Penicillin Allergy

• Use bismuth quadruple therapy (contains no penicillin) 1

Previous Treatment Failures

• Do not reuse antibiotics that failed previously
• After two failed therapies, consider antimicrobial susceptibility testing 1, 4

Administration Guidelines

• PPIs should be taken 30 minutes before meals on an empty stomach
• Bismuth should be taken 30 minutes before meals
• Antibiotics should be taken 30 minutes after meals 1

Confirmation of Eradication

• Test for eradication 4 weeks after completing treatment
• Use urea breath test or monoclonal stool antigen test
• Stop PPIs at least 2 weeks before testing 1

Common Pitfalls and Caveats

1. Inadequate treatment duration: All H. pylori eradication regimens should now be given for 14 days due to increasing treatment failures 5

2. Inappropriate acid suppression: Inadequate acid suppression is associated with treatment failure. Consider high-dose and more potent PPIs in cases of refractory infection 1

3. Clarithromycin resistance: The performance of clarithromycin-containing triple therapies is declining to unacceptable levels in many regions due to increasing antimicrobial resistance 6

4. Patient adherence: Poor compliance significantly reduces eradication rates. Proper patient education about the importance of completing the full course of therapy is essential 7

5. Antibiotic stewardship: Avoid unnecessary antibiotic use. The popular four-drug regimens (concomitant, sequential, or hybrid therapies) may include at least one antibiotic that plays no role in treatment outcome, contributing to global antibiotic resistance 7

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