What are the doses for Helicobacter pylori (H. pylori) treatment?

Helicobacter pylori Treatment Dosing Regimens

The recommended first-line treatment for H. pylori is bismuth quadruple therapy for 14 days, consisting of bismuth subsalicylate, tetracycline HCl, metronidazole, and a proton pump inhibitor (PPI) at high dose. 1

First-Line Treatment Options

Bismuth Quadruple Therapy (Preferred)

• Duration: 14 days
• Components:
  • Bismuth subsalicylate
  • Tetracycline HCl
  • Metronidazole
  • PPI (high-dose): esomeprazole or rabeprazole 40 mg twice daily
• Eradication rate: 85-90% 1

Triple Therapy (When susceptibility is known)

• Duration: 14 days
• Components:
  • Amoxicillin: 1 gram twice daily
  • Clarithromycin: 500 mg twice daily
  • PPI (e.g., lansoprazole): 30 mg twice daily 2

Dual Therapy (Alternative)

• Duration: 14 days
• Components:
  • Amoxicillin: 1 gram three times daily
  • PPI (e.g., lansoprazole): 30 mg three times daily 2

Salvage Therapy Options

For Areas with High Dual Resistance

• Duration: 14 days
• Components:
  • High-dose PPI
  • Amoxicillin
  • Levofloxacin
  • Bismuth 1

Modified Bismuth Quadruple Therapy

• Duration: 14 days
• Components:
  • PPI
  • Amoxicillin
  • Clarithromycin
  • Bismuth 1

Levofloxacin-Based Therapy

• Duration: 10 days
• Components:
  • Levofloxacin: 500 mg twice daily
  • Amoxicillin: 1 gram twice daily
  • PPI (e.g., omeprazole): 20 mg twice daily 3

Important Considerations

PPI Dosing

• Higher-potency PPIs (esomeprazole or rabeprazole 40 mg twice daily) improve eradication rates 1
• Double-dose PPI therapy has shown better (though not statistically significant) eradication rates compared to standard dosing (81.9% vs 73.9%) 4

Treatment Duration

• 14-day regimens are recommended to maximize eradication rates 1
• Shorter courses have lower success rates

Antibiotic Resistance

• Clarithromycin resistance significantly reduces the efficacy of standard triple therapy (20% vs 90% success rate) 5
• Levofloxacin resistance similarly impacts levofloxacin-containing regimens 5
• Susceptibility testing is valuable when available, especially after first-line therapy failure 1, 6

Patient Compliance

• Poor compliance significantly reduces eradication rates
• Thorough patient education about potential side effects is essential
• Common side effects include darkening of stool (bismuth), metallic taste, nausea, and diarrhea 1, 3

Follow-up Testing

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

Pitfalls to Avoid

1. Using clarithromycin-based regimens empirically in areas with high clarithromycin resistance
2. Short treatment duration - 7-day regimens have lower success rates than 14-day regimens
3. Standard PPI dosing - higher doses improve eradication rates
4. Failing to confirm eradication - post-treatment testing is essential
5. Reusing previously failed antibiotics in salvage regimens without susceptibility testing

The treatment landscape for H. pylori continues to evolve with increasing antibiotic resistance. Bismuth-containing quadruple therapy has emerged as the preferred first-line regimen due to its higher eradication rates in the face of increasing clarithromycin resistance 1, 7.