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

Recommended Treatment for Helicobacter pylori Infection

The recommended first-line treatment for H. pylori infection is a 14-day bismuth quadruple therapy consisting of a proton pump inhibitor (PPI), bismuth subsalicylate, tetracycline, and metronidazole, which achieves eradication rates of 85-90%. 1

First-Line Treatment Options

Preferred Regimen: Bismuth Quadruple Therapy (14 days)

• PPI (preferably high-potency like esomeprazole or rabeprazole 40mg twice daily)
• Bismuth subsalicylate
• Tetracycline HCl
• Metronidazole

Alternative First-Line Options:

1. Concomitant Non-Bismuth Quadruple Therapy (14 days)

   • PPI + amoxicillin + metronidazole + clarithromycin
   • Achieves approximately 80% eradication rate 1

2. Triple Therapy (14 days) - Only in areas with known low clarithromycin resistance

   • PPI + clarithromycin + amoxicillin (or metronidazole)
   • As specified in the FDA label: 1g amoxicillin, 500mg clarithromycin, and 30mg lansoprazole, all given twice daily 2
   • Alternative triple therapy: 1g amoxicillin and 30mg lansoprazole, each given three times daily 2

Salvage Therapy Options (After First-Line Failure)

For Areas with High Dual Resistance (clarithromycin and metronidazole):

• 14-day regimen with high-dose PPI + amoxicillin + levofloxacin + bismuth 1

If Susceptibility Testing Shows Clarithromycin Sensitivity:

• 14-day regimen with PPI + bismuth + tetracycline + clarithromycin 1

Modified Bismuth Quadruple Therapy:

• PPI + amoxicillin + clarithromycin + bismuth for 14 days 1

Important Considerations

Treatment Duration

• All H. pylori eradication regimens should be given for 14 days to maximize eradication rates 1, 3

PPI Dosing

• Higher-potency PPIs (esomeprazole or rabeprazole 40mg twice daily) improve eradication rates 1
• PPI should be taken at the start of a meal to minimize gastrointestinal intolerance 2

Patient Compliance

• Poor compliance significantly reduces eradication rates
• Thorough patient education is essential:
  • Inform patients about potential side effects, especially darkening of stool from bismuth
  • Avoid alcohol while taking metronidazole 1

Follow-up Testing

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

Special Populations

Renal Impairment

• Patients with GFR 10-30 mL/min: 500mg or 250mg amoxicillin every 12 hours
• Patients with GFR <10 mL/min: 500mg or 250mg amoxicillin every 24 hours
• Hemodialysis patients: Additional dose during and at end of dialysis 2

Patients with Alarm Symptoms

• Patients ≥55 years or with alarm symptoms should be referred for prompt endoscopy with H. pylori testing 1

Antibiotic Resistance Considerations

The increasing prevalence of antibiotic resistance is a major challenge in H. pylori treatment. The American College of Gastroenterology now recommends bismuth quadruple therapy as the preferred first-line regimen when antibiotic susceptibility is unknown 4. This represents a shift from earlier approaches that relied heavily on clarithromycin-based triple therapy, which is now only recommended in areas with known low clarithromycin resistance 3, 5.

Common Pitfalls to Avoid

1. Using inadequate treatment duration: Always treat for 14 days, not 7 or 10 days 1, 3
2. Failing to test for eradication: Confirmation of eradication is essential
3. Testing too soon after treatment: Wait at least 4 weeks after therapy completion
4. Testing while patient is on PPI: Stop PPI at least 2 weeks before testing
5. Reusing previously failed antibiotics: Avoid antibiotics used in failed regimens
6. Underestimating the importance of compliance: Ensure patients understand the importance of completing the full course

By following these evidence-based recommendations, clinicians can maximize H. pylori eradication rates and improve patient outcomes.