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

H. pylori Treatment Protocol

Bismuth quadruple therapy for 14 days is the preferred first-line treatment regimen for H. pylori infection when antibiotic susceptibility is unknown. 1, 2

First-Line Treatment Options

In areas with high clarithromycin resistance (≥15%):

• Bismuth quadruple therapy (14 days) 1, 3:

  • PPI (twice daily)
  • Bismuth subsalicylate/subcitrate
  • Tetracycline
  • Metronidazole
  • Expected eradication rate: 85%

• Concomitant non-bismuth quadruple therapy (14 days) 1, 3:

  • PPI (twice daily)
  • Clarithromycin
  • Amoxicillin
  • Metronidazole
  • Expected eradication rate: 80%

In areas with low clarithromycin resistance (<15%):

• Standard triple therapy (14 days) 1, 4:

  • PPI (twice daily)
  • Clarithromycin (500 mg twice daily)
  • Amoxicillin (1 gram twice daily)
  • Expected eradication rate: 85%

• Alternative triple therapy 4:

  • PPI (twice daily)
  • Clarithromycin (500 mg twice daily)
  • Metronidazole (when appropriate)

Second-Line Treatment Options

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

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

   • PPI (twice daily)
   • Bismuth subsalicylate/subcitrate
   • Tetracycline
   • Metronidazole
   • Duration: 14 days

2. Levofloxacin-based therapy 1, 5:

   • PPI (twice daily)
   • Amoxicillin (1 gram twice daily)
   • Levofloxacin (500 mg daily)
   • Duration: 14 days
   • Efficacy: 64-73% eradication rate
   • Note: Levofloxacin susceptibility testing recommended before prescribing due to increasing resistance

Third-Line Treatment

For patients with multiple treatment failures:

• Antimicrobial susceptibility testing (AST) should be performed to guide therapy 6, 3
• If AST is not available, use antibiotics not previously used or for which resistance is unlikely 3:
  • Rifabutin-based regimens
  • High-dose dual therapy (PPI plus amoxicillin)
  • Furazolidone-containing regimens

Special Considerations

For penicillin-allergic patients:

• Bismuth quadruple therapy is recommended as first-line 1

Administration timing for optimal effectiveness 1:

• PPIs: 30 minutes before meals
• Bismuth: 30 minutes before meals
• Antibiotics: 30 minutes after meals

Monitoring and follow-up:

• Test for eradication at least 4 weeks after completing treatment 1, 7
• Use urea breath test or monoclonal stool antigen test 1
• Stop PPI at least 2 weeks before testing 1

Common Pitfalls to Avoid

1. Using clarithromycin-based regimens in areas with high resistance (>15-20%) 1, 8
2. Inadequate treatment duration - 14-day regimens are superior to shorter courses 1, 3
3. Poor patient compliance - significantly reduces eradication rates 1
4. Inadequate acid suppression - consider high-dose and more potent PPIs in cases of refractory infection 1
5. Using inappropriate antibiotics - ciprofloxacin is not recommended due to poor efficacy 1
6. Failing to test for eradication - confirmation of eradication is essential 1, 7

By following these evidence-based protocols and considering regional antibiotic resistance patterns, H. pylori eradication can be achieved in the majority of patients, reducing the risk of associated complications such as peptic ulcer disease and gastric cancer.