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

Treatment Regimen for Helicobacter pylori Infection

For H. pylori eradication, a 14-day bismuth quadruple therapy (BQT) is recommended as first-line treatment, 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

First-Line Treatment Options

Treatment selection should be guided by local clarithromycin resistance patterns:

Areas with High Clarithromycin Resistance (≥15%)

1. Bismuth Quadruple Therapy (14 days) 1, 2

   • 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
   • Expected eradication rate: 85%

2. Concomitant Non-Bismuth Quadruple Therapy (14 days) 1, 3

   • PPI twice daily
   • Amoxicillin 1000 mg twice daily
   • Metronidazole 500 mg three times daily
   • Clarithromycin 500 mg twice daily
   • Expected eradication rate: 80%

Areas with Low Clarithromycin Resistance (<15%)

1. Triple Therapy (14 days) 1, 4

   • PPI twice daily
   • Clarithromycin 500 mg twice daily
   • Amoxicillin 1000 mg twice daily
   • Expected eradication rate: 70-85%

2. H. pylori Dual Therapy (14 days) 5

   • Amoxicillin 1 gram three times daily
   • Lansoprazole 30 mg three times daily

Second-Line Treatment Options

If first-line therapy fails, the following options are recommended:

1. Levofloxacin-Based Therapy (14 days) 6, 1

   • PPI twice daily
   • Amoxicillin 1000 mg twice daily
   • Levofloxacin 500 mg once daily
   • Note: Levofloxacin susceptibility testing is recommended before prescribing due to increasing resistance 6

2. Bismuth Quadruple Therapy (14 days) 1

   • If not used as first-line treatment

Third-Line Treatment Options

After two treatment failures:

1. Antimicrobial Susceptibility Testing 6, 1

   • Treatment should be guided by susceptibility testing whenever possible

2. Rifabutin Triple Therapy (14 days) 1

   • PPI twice daily
   • Rifabutin 150 mg twice daily
   • Amoxicillin 1000 mg twice daily

Special Considerations

Penicillin Allergy

• In areas of low clarithromycin resistance: PPI-clarithromycin-metronidazole combination 6
• In areas of high clarithromycin resistance: Bismuth-containing quadruple therapy 6, 1

Medication Administration

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

Treatment Failure Considerations

• Antibiotics that failed previously should not be reused 1
• Inadequate acid suppression is associated with treatment failure; consider high-dose and more potent PPIs in refractory cases 1

Follow-Up Testing

• Test for eradication 4 weeks after completing treatment 6, 1
• Use urea breath test (UBT) or monoclonal stool antigen test 6, 1
• Stop PPIs at least 2 weeks before testing 1

Common Pitfalls and Caveats

1. Antibiotic Resistance

   • Clarithromycin resistance significantly reduces efficacy of standard triple therapy
   • Rapid acquisition of levofloxacin resistance may jeopardize its future efficacy 6
   • Avoid levofloxacin in patients with chronic infectious bronchopneumopathy who may have received fluoroquinolones previously 6

2. Treatment Duration

   • All regimens should be given for 14 days to maximize eradication rates 1, 4, 2
   • Shorter durations are associated with lower success rates

3. Patient Adherence

   • Poor compliance significantly reduces eradication rates 1
   • Patient education about completing the full course is essential
   • Counsel patients about potential side effects, especially darkening of stool from bismuth and the need to avoid alcohol while taking metronidazole 1

4. Previous Antibiotic Exposure

   • Patients with previous macrolide exposure should avoid clarithromycin-based regimens 1
   • Previous treatment failures should guide antibiotic selection