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

Recommended Treatment for H. pylori Infection

Bismuth quadruple therapy for 14 days is the preferred first-line regimen for H. pylori eradication when antibiotic susceptibility is unknown. 1, 2

First-Line Treatment Options

Preferred First-Line Regimen

• Bismuth quadruple therapy (14 days) 1, 2:
  • Proton pump inhibitor (PPI) - high potency (esomeprazole or rabeprazole 40 mg twice daily)
  • Bismuth subsalicylate
  • Tetracycline HCl
  • Metronidazole
  • Expected eradication rate: 85-90%

Alternative First-Line Options

1. Concomitant non-bismuth quadruple therapy (14 days) 1, 3:

   • PPI + Amoxicillin + Metronidazole + Clarithromycin (PAMC)
   • Expected eradication rate: approximately 80%

2. Triple therapy (14 days) - only in areas with known low clarithromycin resistance 1, 3:

   • PPI + Clarithromycin + Amoxicillin
   • OR
   • PPI + Clarithromycin + Metronidazole
   • Expected eradication rate: approximately 85% (when resistance is low)

3. Triple therapy with lansoprazole - for patients allergic or intolerant to clarithromycin 4:

   • Amoxicillin + Lansoprazole

Salvage Therapy (After First-Line Failure)

For Patients Who Failed Initial Therapy

• If susceptibility testing is available: Choose antibiotics based on susceptibility results and avoid previously used antibiotics 1

• Without susceptibility testing (high dual resistance to clarithromycin and metronidazole) 1:

  • 14-day regimen with high-dose PPI + Amoxicillin + Levofloxacin + Bismuth

• If clarithromycin sensitivity is confirmed 1:

  • 14-day regimen with PPI + Bismuth + Tetracycline + Clarithromycin

• After failure of bismuth quadruple therapy 1, 2:

  • Rifabutin-based triple therapy for 14 days

Important Clinical Considerations

PPI Dosing

• Higher-potency PPIs (esomeprazole or rabeprazole 40 mg twice daily) improve eradication rates 1
• PPIs should be taken at the start of a meal to minimize gastrointestinal intolerance 4

Patient Education and Compliance

• Poor compliance significantly reduces eradication rates 1
• Counsel patients about:
  • Potential side effects, especially darkening of stool from bismuth
  • Need to avoid alcohol while taking metronidazole
  • Importance of completing the full 14-day course

Follow-up Testing

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

Special Populations

• Patients with alarm symptoms or age ≥55: Refer for prompt endoscopy with H. pylori testing 1
• Patients with penicillin allergy: Consider allergy testing as many reported allergies are not true allergies; avoid amoxicillin-containing regimens if allergy is confirmed 1

Common Pitfalls to Avoid

1. Using shorter treatment durations: All H. pylori eradication regimens should now be given for 14 days to maximize success rates 1, 3
2. Continuing with the same antibiotics after treatment failure: Avoid previously used antibiotics when selecting salvage therapy 1
3. Not testing for eradication: Always confirm eradication with follow-up testing 1
4. Testing too soon after treatment: Wait at least 4 weeks after treatment completion and stop PPI 2 weeks before testing 1
5. Ignoring antibiotic resistance patterns: Consider local resistance patterns when selecting therapy 1, 2, 5

The evidence strongly supports bismuth quadruple therapy for 14 days as the most effective empiric treatment for H. pylori infection, with eradication rates of 85-90% 1, 2. This approach is particularly important in the era of increasing antibiotic resistance, which has reduced the effectiveness of traditional triple therapy regimens 3, 5.