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

Treatment of Helicobacter pylori Infection

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

First-Line Treatment Options

Based on Clarithromycin Resistance:

High Clarithromycin Resistance Areas (≥15%):

• First choice: Bismuth quadruple therapy for 14 days 1, 2

  • Components: PPI + bismuth + metronidazole + tetracycline
  • Eradication rate: approximately 85%

• Alternative: Concomitant non-bismuth quadruple therapy for 14 days 1, 3

  • Components: PPI + amoxicillin + metronidazole + clarithromycin
  • Eradication rate: approximately 80%

Low Clarithromycin Resistance Areas (<15%):

• PPI-clarithromycin triple therapy for 14 days 1
  • Components: PPI + clarithromycin + amoxicillin
  • FDA-approved regimen: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 4
  • Eradication rate: approximately 85% when given for full 14 days

Second-Line Treatment Options

For patients who fail first-line therapy:

• 14-day levofloxacin triple therapy (if bismuth quadruple was used first) 2
• 14-day bismuth quadruple therapy (if not previously used) 2, 3

Special Considerations

Treatment Duration

• All H. pylori eradication regimens should be given for 14 days to maximize eradication rates 1, 3
• Treatment should continue for a minimum of 48 to 72 hours beyond symptom resolution 4

Test of Cure

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

Multiple Treatment Failures

• Consider antimicrobial susceptibility testing to guide therapy 1, 2
• Rifabutin-containing regimens should be restricted to patients who have failed at least 3 prior options 3, 5

Patient Counseling Points

• Advise patients about potential darkening of stool from bismuth 1
• Warn patients to 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
• Take amoxicillin at the start of a meal to minimize gastrointestinal intolerance 4

Common Pitfalls to Avoid

1. Inadequate treatment duration: Using shorter courses (7-10 days) significantly reduces eradication rates 1, 3
2. Failure to test for eradication: Post-treatment confirmation is essential 1
3. Not stopping PPIs before testing: Can lead to false-negative results 1
4. Continuing to use standard triple therapy in high-resistance areas: Results in unacceptably low eradication rates 2, 6
5. Poor patient compliance: Comprehensive education about the importance of completing the full regimen is crucial 1

Specific FDA-Approved Regimens

• Triple therapy: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 4
• Dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days 4

The choice of regimen should be guided by local antibiotic resistance patterns whenever possible to ensure optimal treatment outcomes and minimize the risk of treatment failure 1, 5.