What treats H. pylori (Helicobacter pylori) infection?

Treatment of Helicobacter pylori Infection

The 14-day bismuth quadruple therapy is the preferred first-line treatment regimen for H. pylori infection 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

First-Line Treatment Options

Recommended Regimens:

1. Bismuth Quadruple Therapy (14 days) - 85% eradication rate 1

   • Proton pump inhibitor (PPI)
   • Bismuth salt
   • Tetracycline
   • Metronidazole or amoxicillin

2. Triple Therapy (14 days) - 85% eradication rate 1, 2

   • PPI (e.g., lansoprazole)
   • Clarithromycin
   • Amoxicillin

3. Concomitant Non-Bismuth Quadruple Therapy (14 days) - 80% eradication rate 1

   • PPI
   • Clarithromycin
   • Amoxicillin
   • Metronidazole

Special Considerations:

• For patients with clarithromycin allergy or resistance: Use bismuth quadruple therapy or consider dual therapy with PPI and amoxicillin 1, 3
• For patients with penicillin allergy: Consider allergy testing as many reported allergies are not true allergies; if confirmed, avoid amoxicillin-containing regimens 1, 3

Second-Line Treatment Options

If first-line treatment fails:

1. "Optimized" Bismuth Quadruple Therapy for patients who haven't received it previously 4
2. Levofloxacin-based triple therapy (levofloxacin, amoxicillin, PPI) for 10 days 5
3. Rifabutin triple therapy for 14 days, especially after failure of optimized bismuth quadruple therapy 4

Medication Administration

• Take medications at the start of a meal to minimize gastrointestinal intolerance 2
• For triple therapy with clarithromycin and lansoprazole, amoxicillin is indicated for adult patients with H. pylori infection and duodenal ulcer disease 2

Patient Education and Compliance

• Inform patients about potential side effects:

  • Darkening of stool from bismuth
  • Avoid alcohol while taking metronidazole (disulfiram-like reaction)
  • Monitor for gastrointestinal symptoms 1

• Poor compliance significantly reduces eradication rates; emphasize the importance of completing the full course 1

Follow-up Testing

• 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

Important Considerations

• Antibiotic resistance is a key factor in treatment failure; local resistance patterns should guide therapy choice 1, 4
• Antimicrobial susceptibility testing should be used whenever possible to ensure effective treatment 1
• Treatment duration of 14 days is generally recommended for optimal eradication rates 1, 4
• For elderly patients or those with multiple comorbidities, a simpler dual therapy with rabeprazole and amoxicillin may be considered 6

Pitfalls to Avoid

• Using clarithromycin-containing regimens in areas with high clarithromycin resistance
• Inadequate treatment duration (shorter than 14 days)
• Not stopping PPIs before follow-up testing
• Using salvage regimens containing clarithromycin or levofloxacin without confirmed antibiotic susceptibility 4
• Failing to educate patients about the importance of completing the full treatment course