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 in regions with high clarithromycin resistance (>15-20%), which is now common in most areas. 1

First-Line Treatment Options

Preferred Regimen

• Bismuth quadruple therapy (14 days):
  • Proton pump inhibitor (PPI) + bismuth + tetracycline + metronidazole 1
  • Achieves approximately 85% eradication rate 1

Alternative Regimens Based on Regional Resistance Patterns

1. In regions with low clarithromycin resistance (<15-20%):

   • Standard triple therapy for 14 days (PPI + amoxicillin + clarithromycin) 1
   • Note: The efficacy of this regimen has declined significantly due to increasing clarithromycin resistance worldwide

2. Sequential therapy (10 days):

   • 5 days of PPI + amoxicillin, followed by
   • 5 days of PPI + clarithromycin + metronidazole 1

3. Concomitant non-bismuth quadruple therapy (14 days):

   • Achieves approximately 80% eradication rate 1

Treatment Selection Algorithm

1. Assess regional antibiotic resistance patterns:

   • If clarithromycin resistance >15-20%: Use bismuth quadruple therapy
   • If clarithromycin resistance <15-20%: Standard triple therapy may be considered

2. Review patient's antibiotic exposure history:

   • Previous macrolide exposure suggests possible clarithromycin resistance
   • Previous metronidazole exposure suggests possible metronidazole resistance

3. Consider patient-specific factors:

   • Penicillin allergy: Avoid amoxicillin-containing regimens
   • Tetracycline contraindications (pregnancy, children <8 years)

Rescue Treatment After Failure

• After failure of clarithromycin-based therapy:

  • Use bismuth quadruple therapy or levofloxacin-based triple therapy 1

• After failure of bismuth quadruple therapy:

  • Use clarithromycin or levofloxacin-based therapy 1

• For multiple treatment failures:

  • Consider rifabutin triple therapy 2
  • Consider antimicrobial susceptibility testing to guide therapy 1

Confirmation of Eradication

• Wait at least 4 weeks after completing antibiotic therapy 1
• Discontinue PPIs for at least 7 days and antibiotics/bismuth for at least 4 weeks before testing 1
• Preferred tests:
  • Urea breath test (sensitivity 95%, specificity 90%)
  • Monoclonal stool antigen test 1

Important Clinical Considerations

• Duration matters: 14-day regimens are more effective than 7-day regimens, improving eradication rates by approximately 5% 1

• PPI dosing: High-dose PPIs improve treatment success 3

• Antibiotic resistance impact:

  • Clarithromycin resistance cannot be overcome by increasing dose or duration 4
  • Metronidazole resistance can often be overcome with higher doses and longer treatment duration 4

• Special populations:

  • For patients with gastric ulcer or MALT lymphoma: Endoscopic follow-up with histological examination is essential 1
  • Patients ≥55 years or with alarm symptoms should undergo prompt endoscopy with H. pylori testing 1

Dietary and Lifestyle Recommendations During Treatment

• Limit acidic, spicy, and fatty foods 1
• Consume fruits and vegetables rich in vitamin C 1
• Limit caffeine and alcohol consumption 1
• Eat smaller, more frequent meals and avoid eating within 3 hours of bedtime 1

Common Pitfalls to Avoid

1. Using standard triple therapy in high clarithromycin resistance regions

   • This approach is now ineffective in many areas due to increasing resistance rates

2. Inadequate treatment duration

   • Short treatment courses (7 days) have lower eradication rates
   • Extend treatment to 14 days for optimal results

3. Testing for eradication too soon

   • Wait at least 4 weeks after treatment completion
   • Premature testing may yield false-negative results

4. Failing to confirm eradication

   • Always confirm eradication to prevent long-term complications
   • H. pylori infection increases risk of peptic ulcer disease, MALT lymphoma, and gastric cancer

5. Retreating with the same antibiotics after failure

   • Acquired resistance is likely after failed treatment
   • Avoid using clarithromycin again after failure of a clarithromycin-containing regimen