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

Best Treatment for Helicobacter pylori Infection

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

Treatment Selection Algorithm

First-Line Treatment

1. Determine local clarithromycin resistance patterns:

   • High resistance (≥15%): 14-day bismuth quadruple therapy
   • Low resistance (<15%): 14-day triple therapy OR 14-day bismuth quadruple therapy

2. Recommended regimens:

   • Bismuth quadruple therapy: PPI + bismuth + tetracycline + metronidazole (85% eradication rate) 1
   • Concomitant non-bismuth quadruple therapy: PPI + amoxicillin + clarithromycin + metronidazole (80% eradication rate) 1
   • Standard triple therapy: PPI + clarithromycin + amoxicillin (85% eradication rate) 1

Second-Line Treatment (After First Treatment Failure)

• 14-day levofloxacin triple therapy OR
• 14-day bismuth quadruple therapy (if not used previously) 2

Antibiotic Resistance Considerations

Antibiotic resistance is the most important factor responsible for the falling success rate of H. pylori eradication treatment 3. Local surveillance of H. pylori antibiotic resistance is mandatory, and the antibiotic combination should be chosen according to local resistance patterns 3.

Key points:

• Clarithromycin resistance cannot be overcome by increasing dose or duration 4
• Metronidazole resistance can often be overcome by increasing dose and duration with acid suppression 4
• Treatment should be guided by antimicrobial susceptibility testing whenever possible 1

Treatment Duration and Verification

• All recommended regimens should be administered for 14 days to maximize eradication rates 1, 2
• Test for eradication at least 4 weeks after completing treatment using:
  • Urea breath test OR
  • Monoclonal stool antigen test
• Stop PPI at least 2 weeks before testing to avoid false negatives 1

Special Considerations

For Multiple Treatment Failures

• Perform antimicrobial susceptibility testing (AST) if available
• If AST is not available, use antibiotics not previously used or for which resistance is unlikely:
  • Amoxicillin
  • Tetracycline
  • Bismuth
  • Furazolidone 2

For Patients with Penicillin Allergy

• Consider allergy testing as many reported penicillin allergies are not true allergies
• Avoid amoxicillin-containing regimens if penicillin allergy is confirmed 1

For High-Risk Patients

Surveillance endoscopy should be performed every 3 years in patients with:

• Risk factors for gastric cancer
• Atrophic gastritis 1

Common Pitfalls and How to Avoid Them

1. Inadequate treatment duration: Always treat for 14 days to maximize eradication rates 1, 2

2. Failure to test for eradication: Always confirm eradication at least 4 weeks after treatment completion 1

3. Poor patient compliance: Educate patients about:

   • Importance of completing the full course
   • Potential side effects (darkening of stool from bismuth)
   • Need to avoid alcohol while taking metronidazole 1

4. Not stopping PPIs before testing: Stop PPIs at least 2 weeks before testing for eradication to avoid false negatives 1

5. Using clarithromycin in areas with high resistance: In areas with high clarithromycin resistance, bismuth quadruple therapy should be used instead of clarithromycin-containing regimens 1, 2