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

Treatment of Helicobacter pylori Infection

Bismuth quadruple therapy for 14 days is the preferred first-line treatment for H. pylori infection when antibiotic susceptibility is unknown. 1

First-Line Treatment Options

Preferred First-Line Regimen

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

Alternative First-Line Options

1. Triple therapy for patients with confirmed H. pylori and duodenal ulcer disease:

   • Amoxicillin + clarithromycin + lansoprazole 2
   • Only recommended in areas with low clarithromycin resistance

2. Dual therapy for patients allergic or intolerant to clarithromycin:

   • Amoxicillin + lansoprazole 2

Salvage Therapy After Treatment Failure

Second-Line Treatment

• For areas with high dual resistance (clarithromycin and metronidazole):

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

• If clarithromycin sensitivity is confirmed:

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

Third-Line and Beyond

• Modified bismuth quadruple therapy:

  • PPI + amoxicillin + clarithromycin + bismuth for 14 days 1
  • Particularly effective when previous quadruple therapy included bismuth, tetracycline, metronidazole, and PPI

• Rifabutin-based regimens:

  • Useful as salvage therapy, particularly after bismuth quadruple therapy failure 3

Key Principles for Optimal Treatment

Optimizing Treatment Success

• Use 14-day regimens to maximize eradication rates 1
• Prescribe higher-potency PPIs (esomeprazole or rabeprazole 40 mg twice daily) 1
• Avoid previously used antibiotics when possible 1
• Consider antibiotic susceptibility testing, especially after first-line failure 1, 4

Patient Education and Compliance

• Poor compliance significantly reduces eradication rates 1
• Inform patients about:
  • Potential side effects (darkening of stool from bismuth)
  • Avoiding alcohol while taking metronidazole
  • Importance of completing the full course of treatment

Follow-Up Testing

• Test for eradication at least 4 weeks after completing treatment 1
• Stop PPI at least 2 weeks before testing 1
• Preferred tests:
  • 13C-Urea Breath Test (sensitivity 95%, specificity 90%)
  • Monoclonal stool antigen test (comparable accuracy to breath test) 1

Special Considerations

• Patients with alarm symptoms or age ≥55: Refer for prompt endoscopy with H. pylori testing 1
• Penicillin allergy: Consider allergy testing as many reported allergies are not true allergies; avoid amoxicillin-containing regimens if confirmed 1
• Surveillance: Perform endoscopy every 3 years in patients with risk factors for gastric cancer or atrophic gastritis 1

Common Pitfalls to Avoid

• Using clarithromycin-containing triple therapies empirically (declining efficacy due to resistance) 4
• Inadequate treatment duration (less than 14 days) 1
• Using standard-dose PPIs instead of high-dose 1
• Failing to confirm eradication after treatment 1
• Reusing antibiotics that were used in failed previous treatments 1