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

Recommended Treatment for Helicobacter pylori Infection

The first-line treatment for H. pylori infection is bismuth quadruple therapy for 14 days, consisting of a PPI (twice daily), bismuth subsalicylate/subcitrate, tetracycline, and metronidazole, with an expected eradication rate of 85%. 1

First-Line Treatment Options

Bismuth Quadruple Therapy (Preferred)

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

Alternative First-Line Regimens

1. Standard Triple Therapy (in areas with low clarithromycin resistance <15%)

   • PPI (twice daily)
   • Amoxicillin (1 gram twice daily)
   • Clarithromycin (500 mg twice daily)
   • Duration: 14 days
   • Expected eradication rate: 85%

2. Concomitant Non-Bismuth Quadruple Therapy

   • PPI (twice daily)
   • Amoxicillin
   • Clarithromycin
   • Metronidazole
   • Duration: 14 days
   • Expected eradication rate: 80%

Special Considerations

For Patients with Penicillin Allergy

• Bismuth quadruple therapy is the recommended first-line treatment 1

For Patients Previously Treated with Clarithromycin

• Avoid clarithromycin-containing regimens due to potential resistance
• Use bismuth quadruple therapy instead 1, 2

Testing for Eradication

• Test for eradication at least 4 weeks after completing treatment 1
• Use non-invasive testing methods:
  • 13C-urea breath test (UBT) - sensitivity 95%, specificity 90%
  • Laboratory-based validated monoclonal stool antigen test
• Stop PPI at least 2 weeks before testing 1

Second-Line Treatment Options

If first-line treatment fails:

1. Levofloxacin-Based Triple Therapy

   • PPI (twice daily)
   • Amoxicillin
   • Levofloxacin
   • Duration: 10-14 days
   • Expected eradication rate: 64-73%
   • Consider local fluoroquinolone resistance patterns 1

2. Bismuth Quadruple Therapy (if not used as first-line)

   • Follow the same regimen as described above

FDA-Approved Regimens

The FDA specifically approves two regimens for H. pylori eradication 3:

1. Triple Therapy

   • Amoxicillin (1 gram twice daily)
   • Clarithromycin (500 mg twice daily)
   • Lansoprazole (30 mg twice daily)
   • Duration: 14 days

2. Dual Therapy

   • Amoxicillin (1 gram three times daily)
   • Lansoprazole (30 mg three times daily)
   • Duration: 14 days
   • For patients allergic/intolerant to clarithromycin or with clarithromycin-resistant H. pylori

Patient Counseling and Adherence

• Advise patients about potential side effects:
  • Darkening of stool from bismuth
  • Avoid alcohol while taking metronidazole (disulfiram-like reaction)
  • Gastrointestinal symptoms
• Take medications with food to minimize gastrointestinal intolerance 3
• Poor compliance significantly reduces eradication rates; stress the importance of completing the full course 1

Follow-up and Surveillance

• For patients with risk factors for gastric cancer or atrophic gastritis, surveillance endoscopy should be performed every 3 years 1
• For patients with peptic ulcer disease, confirm eradication to prevent recurrence 3, 2

Important Caveats

• Treatment duration of 14 days is superior to 7 or 10 days for most regimens, with significantly higher eradication rates 4
• Resistance to clarithromycin is increasing globally, which may impact the efficacy of standard triple therapy 2, 5
• High-dose PPIs improve eradication rates compared to standard doses 6

Remember that successful H. pylori eradication reduces the risk of duodenal ulcer recurrence and may restore gastric homeostasis 3, 2.