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

Treatment for Helicobacter pylori Infection

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

First-Line Treatment Options

Preferred First-Line Regimen:

• Bismuth quadruple therapy (14 days) 1
  • PPI (twice daily)
  • Bismuth subsalicylate/subcitrate
  • Tetracycline
  • Metronidazole
  • Expected eradication rate: 85%

Alternative First-Line Options:

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

   • PPI-clarithromycin-containing triple therapy (14 days) 1
   • Triple therapy with clarithromycin, amoxicillin, and lansoprazole 3

2. For patients with penicillin allergy:

   • For non-anaphylactic penicillin allergy who can tolerate cephalosporins: Cefuroxime, levofloxacin, PPI, and bismuth potassium citrate (14 days) 1
   • PPI (twice daily) + Clarithromycin + Levofloxacin (10 days) - efficacy 64-73% 1

Second-Line/Rescue Therapy Options

If first-line treatment fails:

• Levofloxacin-based therapy: PPI (twice daily), Amoxicillin (1g twice daily), and Levofloxacin (500mg daily) 1
• PPI, clarithromycin, and levofloxacin for 10 days 1
• Avoid antibiotics where resistance is expected (e.g., clarithromycin if previously used) 4

Treatment Optimization Tips

1. Medication Administration:

   • PPIs: Take 30 minutes before meals
   • Bismuth: Take 30 minutes before meals
   • Antibiotics: Take 30 minutes after meals 1

2. Dosing Considerations:

   • Higher doses of metronidazole (1.5-2g/day) improve eradication rates in areas with high metronidazole resistance 1
   • Adequate acid suppression is critical - consider higher doses of PPI or more potent PPIs like esomeprazole or rabeprazole 1

3. Duration:

   • 14-day treatment duration is recommended for all regimens to maximize eradication rates 1, 5

Follow-Up and Testing

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

Special Considerations

1. Antibiotic Resistance:

   • Clarithromycin resistance cannot be overcome by increasing dose or duration 4
   • Metronidazole resistance can often be overcome by increasing dose and duration 4

2. Patient Education:

   • Inform about potential darkening of stool from bismuth 1
   • Avoid alcohol while taking metronidazole due to disulfiram-like reaction 1
   • Emphasize importance of completing full course to avoid treatment failure 1

3. Penicillin Allergy:

   • Consider allergy testing after failure of first-line therapy 1
   • Many reported penicillin allergies are not true allergies 1

Common Pitfalls to Avoid

1. Inadequate treatment duration - 14 days is optimal for most regimens 1, 5
2. Poor patient compliance - significantly reduces eradication rates 1
3. Inappropriate acid suppression - inadequate PPI dosing can lead to treatment failure 1
4. Reusing antibiotics after treatment failure - especially clarithromycin 4
5. Not confirming eradication - post-treatment testing is essential 1

For patients with multiple treatment failures, consider antimicrobial susceptibility testing to guide therapy selection 5, 2.