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

Recommended Treatment for Helicobacter pylori Infection

For H. pylori eradication, bismuth-containing quadruple therapy for 14 days is the recommended first-line treatment in areas of high clarithromycin resistance, while PPI-clarithromycin-containing triple therapy or bismuth quadruple therapy for 14 days is recommended in areas of low clarithromycin resistance. 1, 2

First-line Treatment Options

Areas of High Clarithromycin Resistance (≥15%)

1. Bismuth Quadruple Therapy (14 days)

   • PPI (twice daily)
   • Bismuth subsalicylate/subcitrate
   • Tetracycline
   • Metronidazole
   • Expected eradication rate: 85% 2

2. Concomitant Non-bismuth Quadruple Therapy (14 days)

   • PPI (twice daily)
   • Amoxicillin
   • Metronidazole
   • Clarithromycin 2, 3

Areas of Low Clarithromycin Resistance (<15%)

1. PPI Triple Therapy (14 days)

   • PPI (twice daily)
   • Clarithromycin
   • Amoxicillin or metronidazole 1, 2

2. Bismuth Quadruple Therapy (14 days) - as described above

Second-line Treatment Options

After failure of a PPI-clarithromycin-containing treatment:

1. Bismuth Quadruple Therapy (14 days) - if not used as first-line
2. Levofloxacin-containing Triple Therapy (10 days)
   • PPI (twice daily)
   • Amoxicillin
   • Levofloxacin 1, 2

Important note: Rising rates of levofloxacin resistance should be taken into account when prescribing levofloxacin-containing regimens 1

Third-line Treatment Options

After failure of second-line therapy:

• Treatment should be guided by antimicrobial susceptibility testing whenever possible 1
• If testing is not available, use antibiotics not previously used, such as rifabutin 1, 4

Special Considerations

Penicillin Allergy

• In areas of low clarithromycin resistance: PPI-clarithromycin-metronidazole combination
• In areas of high clarithromycin resistance: Bismuth-containing quadruple therapy 1
• As a rescue regimen in areas of low fluoroquinolone resistance: Levofloxacin-containing regimen (with PPI and clarithromycin) 1

H. pylori Eradication Confirmation

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

Specific FDA-Approved Regimens for H. pylori

Triple Therapy (14 days)

• 1 gram amoxicillin (twice daily)
• 500 mg clarithromycin (twice daily)
• 30 mg lansoprazole (twice daily) 5

Dual Therapy (14 days)

• 1 gram amoxicillin (three times daily)
• 30 mg lansoprazole (three times daily) 5
• Note: Dual therapy is indicated for patients allergic or intolerant to clarithromycin or when clarithromycin resistance is known/suspected 5

Common Pitfalls and Caveats

1. Duration of treatment: All H. pylori eradication regimens should now be given for 14 days to improve eradication rates 6

2. Antibiotic resistance: Local patterns of antibiotic resistance significantly impact treatment success. Clarithromycin resistance is a major concern globally 3, 7

3. Patient compliance: Poor compliance significantly reduces eradication rates. Patient education about completing the full course is essential 2

4. Medication timing: To minimize gastrointestinal intolerance, amoxicillin should be taken at the start of a meal 5

5. Drug interactions: Patients should avoid alcohol while taking metronidazole due to disulfiram-like reaction 2

6. Follow-up testing: Failure to confirm eradication can lead to persistent infection and complications 2

The treatment approach should be guided by local antibiotic resistance patterns whenever possible, with bismuth quadruple therapy emerging as a preferred option in many regions due to increasing clarithromycin resistance 4.