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

Treatment for H. pylori Infection

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

First-Line Treatment Options

Preferred Regimen:

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

Alternative First-Line Options:

1. Triple Therapy (14 days) 1, 3

   • 1 gram amoxicillin (twice daily)
   • 500 mg clarithromycin (twice daily)
   • 30 mg lansoprazole (twice daily)
   • Recommended 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%

Second-Line Treatment Options

If first-line therapy fails, consider:

1. Levofloxacin Triple Therapy (14 days) 1, 5

   • PPI (twice daily)
   • Amoxicillin
   • Levofloxacin
   • Efficacy: 64-73% eradication rate

2. Bismuth Quadruple Therapy (14 days) 1

   • If not previously used as first-line

Special Considerations

Penicillin Allergy

• For patients with amoxicillin allergy, bismuth quadruple therapy is recommended as first-line treatment 1

Multiple Treatment Failures

• After two treatment failures, consider antimicrobial susceptibility testing 4, 2
• If testing is unavailable, use antibiotics not previously used or for which resistance is unlikely (amoxicillin, tetracycline, bismuth, or furazolidone) 4
• Levofloxacin-based rescue therapy can be an effective third-line option 6

Testing for Eradication

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

Patient Counseling

• Take medications with meals to minimize gastrointestinal intolerance 3
• Warn 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, as poor compliance significantly reduces eradication rates 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
• Consider follow-up testing to confirm eradication, especially in high-risk patients 2, 7

Common Pitfalls

1. Inadequate treatment duration: 14-day regimens are superior to shorter courses
2. Ignoring antibiotic resistance patterns: Local resistance patterns should guide therapy selection
3. Poor patient adherence: Emphasize the importance of completing the full treatment course
4. Premature post-treatment testing: Testing before 4 weeks can lead to false-negative results

The increasing antimicrobial resistance, particularly to clarithromycin, has made bismuth quadruple therapy the preferred first-line treatment in most regions, especially when antibiotic susceptibility is unknown 5, 2.