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 either bismuth quadruple therapy (PPI, bismuth, tetracycline, and metronidazole) or concomitant non-bismuth quadruple therapy (PPI, amoxicillin, metronidazole, and clarithromycin), both given for 14 days to maximize eradication rates. 1

First-Line Treatment Options

Bismuth Quadruple Therapy (14 days)

• Proton pump inhibitor (PPI) - high-potency (e.g., esomeprazole or rabeprazole 40 mg twice daily)
• Bismuth subsalicylate
• Tetracycline HCl
• Metronidazole
• Eradication rate: 85-90% 1

Concomitant Non-Bismuth Quadruple Therapy (14 days)

• PPI (high-potency)
• Amoxicillin
• Metronidazole
• Clarithromycin
• Eradication rate: approximately 80% 1

Triple Therapy (14 days)

For areas with known low clarithromycin resistance:

• 1 gram amoxicillin twice daily
• 500 mg clarithromycin twice daily
• 30 mg lansoprazole twice daily
• Eradication rate: approximately 85% 1, 2

Alternative Triple Therapy Option (14 days)

• 1 gram amoxicillin three times daily
• 30 mg lansoprazole three times daily 2

Important Considerations for Treatment

Duration

All H. pylori eradication regimens should be given for 14 days to maximize eradication rates 1. Shorter durations have been associated with lower success rates.

PPI Dosing

Higher-potency PPIs (esomeprazole or rabeprazole 40 mg twice daily) are recommended to improve eradication rates 1. PPIs 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 about the importance of completing the full course of treatment is essential 1. Inform patients about potential side effects, especially darkening of stool from bismuth and the need to avoid alcohol while taking metronidazole.

Salvage Therapy (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

Follow-Up Testing

Test for eradication at least 4 weeks after completing treatment using:

• Urea breath test (sensitivity 95%, specificity 90%)
• Monoclonal stool antigen test (equivalent accuracy to urea breath test) 1

Important: Stop PPI at least 2 weeks before testing to avoid false negatives.

Special Considerations

Penicillin Allergy

Consider allergy testing, as many patients with reported penicillin allergy do not have true allergy. If penicillin allergy is confirmed, avoid amoxicillin-containing regimens 1.

Renal Impairment

Patients with severe renal impairment (GFR <30 mL/min) should NOT receive the 875 mg dose of amoxicillin. Adjust dosing according to severity of renal impairment 2:

• GFR 10-30 mL/min: 500 mg or 250 mg every 12 hours
• GFR <10 mL/min: 500 mg or 250 mg every 24 hours
• Hemodialysis: 500 mg or 250 mg every 24 hours, with additional dose during and at end of dialysis

Alarm Symptoms

Patients with age ≥55 or presence of alarm symptoms should be referred for prompt endoscopy with H. pylori testing 1.

Common Pitfalls to Avoid

1. Using shorter treatment durations (less than 14 days)
2. Not considering local antibiotic resistance patterns
3. Using standard-dose PPIs instead of high-potency PPIs
4. Not educating patients about the importance of compliance
5. Not stopping PPIs before follow-up testing
6. Repeating previously failed antibiotics in salvage therapy