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

Recommended Treatment for H. Pylori Infection

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

First-Line Treatment Options

Preferred First-Line Regimen

• Bismuth Quadruple Therapy (14 days) 1, 2
  • PPI (twice daily)
  • Bismuth subsalicylate/subcitrate
  • Tetracycline
  • Metronidazole
  • Expected eradication rate: 85%

Alternative First-Line Regimens

1. Triple Therapy (14 days) 3

   • PPI (twice daily)
   • Amoxicillin (1 gram twice daily)
   • Clarithromycin (500 mg twice daily)
   • Expected eradication rate: 85% (in areas with low clarithromycin resistance <15%)

2. Concomitant Non-Bismuth Quadruple Therapy (14 days) 1, 4

   • PPI (twice daily)
   • Amoxicillin
   • Clarithromycin
   • Metronidazole
   • Expected eradication rate: 80% (in areas with high clarithromycin resistance ≥15%)

Treatment Selection Based on Clarithromycin Resistance

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

  • 14-day bismuth quadruple therapy OR
  • 14-day concomitant therapy 4

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

  • 14-day triple therapy OR
  • 14-day bismuth quadruple therapy 4

Second-Line Treatment Options

If first-line treatment fails:

• If bismuth quadruple therapy was not previously used:

  • 14-day bismuth quadruple therapy 1, 4

• If bismuth quadruple therapy was previously used:

  • 14-day levofloxacin triple therapy 1, 4
    • PPI (twice daily)
    • Amoxicillin (1 gram twice daily)
    • Levofloxacin (500 mg twice daily)
    • Expected efficacy: 64-73% 1

Third-Line Treatment Options

For patients with multiple treatment failures:

• Rifabutin-based triple therapy 2
• Antibiotic susceptibility testing (AST) guided therapy 4, 2
• Levofloxacin-based rescue therapy 5
  • Levofloxacin (500 mg twice daily)
  • Amoxicillin (1 gram twice daily)
  • PPI (20 mg twice daily)
  • Duration: 10 days
  • Expected efficacy: 66% 5

Special Considerations

Patients with Penicillin Allergy

• Bismuth quadruple therapy is the preferred regimen 1

Monitoring and Follow-up

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

Patient Counseling

• Advise patients about potential darkening of stool from bismuth 1
• Avoid alcohol while taking metronidazole due to disulfiram-like reaction 1
• Emphasize the importance of completing the full course of treatment 1
• Poor compliance significantly reduces eradication rates 1

Common Pitfalls to Avoid

1. Inadequate duration of therapy - 14-day regimens are superior to shorter courses 1, 6
2. Not testing for cure - Confirmation of eradication is essential 1
3. Repeating failed regimens - Use different antibiotics for subsequent treatment attempts 4, 2
4. Not considering local resistance patterns - Treatment should be guided by regional antibiotic resistance data when available 4, 6
5. Inadequate acid suppression - High-dose PPI improves eradication rates 6

By following these evidence-based recommendations, clinicians can maximize the chances of successful H. pylori eradication while minimizing the risk of antibiotic resistance development.