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

Recommended Treatment Regimens for H. 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 HCl, and metronidazole, which achieves eradication rates of 85-90%. 1

First-Line Treatment Options

Bismuth Quadruple Therapy (Preferred)

• Standard regimen (14 days):
  • PPI (high-dose: 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 (PAMC)
   • Eradication rate: approximately 80% 1, 2

2. Standard Triple Therapy (14 days):

   • Only in areas with known low clarithromycin resistance
   • PPI + Clarithromycin + Amoxicillin/Metronidazole
   • Eradication rate: approximately 85% when used for full 14 days 1, 2

3. FDA-Approved Dual Therapy (14 days): 3

   • 1 gram amoxicillin and 30 mg lansoprazole, three times daily

Salvage Therapy Options (After First-Line Failure)

For Areas with High Dual Resistance (Clarithromycin and Metronidazole):

• 14-day regimen: High-dose PPI + Amoxicillin + Levofloxacin + Bismuth 1

If Susceptibility Testing Shows Clarithromycin Sensitivity:

• 14-day regimen: PPI + Bismuth + Tetracycline + Clarithromycin 1

Modified Bismuth Quadruple Therapy:

• 14-day regimen: PPI + Amoxicillin + Clarithromycin + Bismuth 1

Key Treatment Considerations

Treatment Duration

• All H. pylori regimens should be given for 14 days to maximize eradication rates 1, 2
• Shorter durations (5-10 days) have shown significantly lower success rates 4, 5

PPI Dosing

• Higher-potency PPIs (esomeprazole or rabeprazole 40 mg twice daily) improve eradication rates 1
• Standard PPI dosing may result in suboptimal acid suppression and lower eradication rates

Patient Compliance

• Poor compliance significantly reduces eradication rates
• Thorough patient education is essential:
  • Inform patients about potential side effects (darkening of stool from bismuth)
  • Advise avoiding alcohol while taking metronidazole
  • Stress importance of completing full course of treatment 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

Penicillin Allergy

• Consider allergy testing as many reported allergies are not true allergies
• If confirmed, avoid amoxicillin-containing regimens 1, 6
• Use bismuth quadruple therapy without amoxicillin

Pregnancy and Breastfeeding

• Most medications used for H. pylori treatment are compatible with breastfeeding
• Avoid invasive diagnostic procedures during pregnancy unless absolutely necessary
• If needed, perform preferably in the second trimester 1, 6

Common Pitfalls to Avoid

1. Using shorter treatment durations: The Toronto Consensus strongly recommends 14-day regimens due to increasing failure rates with shorter courses 2

2. Continuing with triple therapy in high resistance areas: Traditional clarithromycin triple therapy now provides unacceptably low treatment success in many regions 7

3. Inadequate PPI dosing: Using standard PPI doses rather than high-dose PPIs can reduce eradication rates 1

4. Not testing for eradication: Failure to confirm eradication can lead to persistent infection and complications 1

5. Reusing previously failed antibiotics: For salvage therapy, avoid antibiotics used in previous failed regimens 1