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

Recommended Treatment for Helicobacter pylori Infection

In areas of high clarithromycin resistance (≥15%), bismuth quadruple therapy for 14 days is the recommended first-line treatment for H. pylori infection, while in areas of low clarithromycin resistance (<15%), PPI-clarithromycin-containing triple therapy for 14 days is recommended. 1

First-Line Treatment Options

Based on Clarithromycin Resistance:

1. High Clarithromycin Resistance Areas (≥15%):

   • Bismuth quadruple therapy for 14 days (85% eradication rate) 1
   • Components: PPI + bismuth + tetracycline + metronidazole
   • Alternative: Concomitant non-bismuth quadruple therapy for 14 days (80% eradication rate) 1

2. Low Clarithromycin Resistance Areas (<15%):

   • Standard triple therapy for 14 days (85% eradication rate) 1
   • Components: PPI + clarithromycin + amoxicillin
   • Alternative: Bismuth quadruple therapy for 14 days 1

Special Treatment Considerations

For Patients with Penicillin Allergy:

• Avoid amoxicillin-containing regimens 1
• Consider allergy testing as many reported penicillin allergies are not true allergies 1
• Alternative regimen: bismuth quadruple therapy without amoxicillin

For Treatment-Experienced Patients:

• Use antibiotics not previously used or for which resistance is unlikely 2
• Second-line options: 14-day levofloxacin triple therapy or 14-day bismuth quadruple therapy (if not previously used) 2
• For multiple treatment failures, antimicrobial susceptibility testing is recommended 2

For Patients with Duodenal Ulcer:

• Triple therapy with amoxicillin, clarithromycin, and lansoprazole 3
• For patients allergic or intolerant to clarithromycin, or with suspected resistance: dual therapy with amoxicillin and lansoprazole 3

Optimizing Treatment Success

1. Acid Suppression:

   • Use high-dose potent proton pump inhibitors or vonoprazan for adequate acid suppression 2
   • Take medications at the start of a meal to minimize gastrointestinal intolerance 3

2. Treatment Duration:

   • All regimens should be administered for 14 days to maximize eradication rates 1, 2
   • Shorter courses have lower eradication rates 1

3. Patient Counseling:

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

Post-Treatment Follow-up

• Test for eradication at least 4 weeks after completing treatment 1
• Use urea breath test or monoclonal stool antigen test 1
• Discontinue PPIs at least 2 weeks before testing to avoid false negatives 1
• The stool antigen test 7 days after treatment completion can be predictive of eradication success 4

Common Pitfalls to Avoid

1. Inadequate treatment duration - ensure full 14-day course 1
2. Failure to test for eradication after treatment 1
3. Poor patient compliance - provide clear instructions and emphasize importance 1
4. Not stopping PPIs before testing - can lead to false negative results 1
5. Misdiagnosis of GERD as H. pylori infection - carefully assess predominant symptoms 1

Special Populations

• Pregnancy: Avoid invasive diagnostic procedures unless absolutely necessary; if needed, perform preferably in second trimester 1
• Breastfeeding: Most medications used for H. pylori treatment are compatible with breastfeeding 1
• Patients with risk factors for gastric cancer: Consider surveillance endoscopy every 3 years 1