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

Recommended Treatment Regimens for Helicobacter pylori Infection

Bismuth quadruple therapy for 14 days is the recommended first-line treatment for H. pylori infection due to increasing clarithromycin resistance worldwide. 1, 2

First-Line Treatment Options

Preferred First-Line Regimen:

• Bismuth quadruple therapy (14 days):
  • Proton pump inhibitor (PPI) twice daily
  • Bismuth subsalicylate/subcitrate
  • Tetracycline (500 mg four times daily)
  • Metronidazole (500 mg three-four times daily)

Alternative First-Line Regimen (if bismuth unavailable):

• Concomitant non-bismuth quadruple therapy (14 days):
  • PPI twice daily
  • Amoxicillin (1000 mg twice daily)
  • Clarithromycin (500 mg twice daily)
  • Metronidazole (500 mg twice daily)

Important Considerations:

• Standard triple therapy (PPI + clarithromycin + amoxicillin) is no longer recommended as first-line treatment in areas with high clarithromycin resistance (≥15%) 1, 2
• Triple therapy may still be used in areas with low clarithromycin resistance (<15%) 2
• Higher doses of PPI improve eradication rates 2
• 14-day regimens show superior eradication rates compared to shorter courses 2

Second-Line Treatment Options

If first-line treatment fails, the choice of second-line therapy depends on what was used initially:

• If bismuth quadruple therapy failed:

  • Levofloxacin-based triple therapy (10-14 days):
    • PPI twice daily
    • Levofloxacin (500 mg twice daily)
    • Amoxicillin (1 g twice daily) 2, 3

• If non-bismuth regimen failed:

  • Bismuth quadruple therapy (14 days) as described above 1

Third-Line Treatment Options

For patients who have failed two previous treatment attempts:

• Levofloxacin-based rescue therapy:

  • PPI twice daily
  • Levofloxacin (500 mg twice daily)
  • Amoxicillin (1 g twice daily) for 10 days 3

• Alternative options:

  • Rifabutin-based triple therapy
  • High-dose dual amoxicillin-PPI therapy 1, 4

Special Considerations

Antibiotic Resistance:

• Clarithromycin resistance rates exceed acceptable thresholds in many regions, limiting its empiric use 2
• Previous exposure to clarithromycin, levofloxacin, or metronidazole increases risk of resistance; avoid these antibiotics in subsequent attempts if previously used 1

Confirmation of Eradication:

• Universal post-treatment testing is essential to confirm eradication 2
• Use urea breath test (UBT) or stool antigen test at least 4 weeks after completion of therapy 2
• Avoid testing within 4 weeks of PPI use or 2 weeks of antibiotic use to prevent false negatives

Treatment Administration:

• Amoxicillin should be taken at the start of a meal to minimize gastrointestinal intolerance 5
• For H. pylori triple therapy in adults: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 5
• For dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days 5

Common Pitfalls to Avoid

1. Using clarithromycin-based regimens empirically in areas with high resistance rates (≥15%)
2. Short treatment duration - 14 days is now standard for all regimens
3. Failing to confirm eradication after treatment completion
4. Reusing previously failed antibiotics in subsequent treatment attempts
5. Inadequate acid suppression - higher doses of PPIs improve eradication rates

The goal of treatment should be to achieve an eradication rate of over 80%, with the choice of regimen based on local antibiotic resistance patterns and the patient's previous antibiotic exposure history 2, 4.