What are the current guidelines for treating H. pylori (Helicobacter pylori) infection?

Current Guidelines for H. pylori Infection Treatment

Bismuth quadruple therapy for 14 days is the recommended first-line treatment for H. pylori infection in regions with high clarithromycin resistance (>15-20%). 1

First-Line Treatment Options

Treatment selection should be based on regional antibiotic resistance patterns:

• High clarithromycin resistance regions (>15-20%):

  • First choice: Bismuth quadruple therapy (PPI + bismuth + tetracycline + metronidazole) for 14 days (85% eradication rate) 1
  • Alternative: Concomitant non-bismuth quadruple therapy (PPI + clarithromycin + amoxicillin + metronidazole) for 14 days (80% eradication rate) 1

• Low clarithromycin resistance regions (<15-20%):

  • Standard triple therapy (PPI + amoxicillin + clarithromycin) for 14 days (85% eradication rate) 1

Specific Regimens

1. Triple therapy (in regions with low clarithromycin resistance):

   • Amoxicillin 1g, clarithromycin 500mg, and PPI (e.g., lansoprazole 30mg), all twice daily for 14 days 2

2. Dual therapy (alternative option):

   • Amoxicillin 1g and lansoprazole 30mg, each three times daily for 14 days 2

Second-Line Treatment Options

After failure of first-line therapy:

• Bismuth quadruple therapy (if not used initially) 1
• Levofloxacin-based triple therapy 1, 3

For refractory cases with two failed therapies:

• Rifabutin-based triple therapy 1, 3
• High-dose dual therapy 1

Antibiotic Resistance Testing

• After two failed therapies with confirmed patient adherence, H. pylori susceptibility testing should guide subsequent regimen selection 1, 3
• Molecular testing methods can provide convenient characterization of H. pylori antibiotic susceptibility 4

Important Considerations for Treatment

PPI Administration

• Optimal PPI dosing is 30 minutes prior to eating or drinking on an empty stomach 1
• Avoid concomitant use of other antacids (e.g., H2 receptor antagonists) 1

Treatment Duration

• 14-day regimens are strongly recommended for all treatment options 1, 4
• Extending treatment from 7 to 14 days improves eradication success by approximately 5% 1

Medication Administration

• To minimize gastrointestinal intolerance, amoxicillin should be taken at the start of a meal 2

Confirmation of Eradication

• Wait at least 4 weeks after completing antibiotic therapy before testing for H. pylori eradication 1
• Urea Breath Test (UBT) is the gold standard non-invasive test (sensitivity 95%, specificity 90%) 1
• Monoclonal stool antigen test is an acceptable alternative with equivalent accuracy 1

Special Populations

Renal Impairment

• Patients with GFR 10-30 mL/min: 500mg or 250mg amoxicillin every 12 hours 2
• Patients with GFR <10 mL/min: 500mg or 250mg amoxicillin every 24 hours 2
• Hemodialysis patients: Administer an additional dose both during and at the end of dialysis 2

Pregnancy

• Avoid invasive diagnostic procedures unless absolutely necessary; if needed, perform preferably in the second trimester 1

Common Pitfalls to Avoid

1. Using clarithromycin-containing regimens empirically in high-resistance regions

   • This leads to unacceptably low eradication rates 4, 3

2. Inadequate treatment duration

   • 7-day regimens have significantly lower success rates compared to 14-day regimens 5

3. Failing to test for eradication

   • Confirmation of eradication is essential to ensure treatment success 1

4. Not considering previous antibiotic exposure

   • A thorough review of the patient's antibiotic history is essential before selecting a treatment regimen 1

5. Retreating with the same regimen after failure

   • Different antibiotic combinations should be used for second-line therapy 3, 6