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

Treatment for 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%), while standard triple therapy for 14 days is recommended in regions with low clarithromycin resistance (<15-20%). 1

First-Line Treatment Options

Recommended Regimens:

1. Bismuth quadruple therapy (14 days) - 85% eradication rate 1

   • Proton pump inhibitor (PPI)
   • Bismuth
   • Tetracycline
   • Metronidazole

2. Standard triple therapy (14 days) - 85% eradication rate 1

   • PPI
   • Amoxicillin
   • Clarithromycin
   • Note: Only recommended in regions with low clarithromycin resistance (<15-20%)

3. Concomitant non-bismuth quadruple therapy (14 days) - 80% eradication rate 1

   • PPI
   • Clarithromycin
   • Amoxicillin
   • Metronidazole

4. FDA-approved triple therapy 2

   • Amoxicillin
   • Clarithromycin
   • Lansoprazole

5. FDA-approved dual therapy (for clarithromycin allergy/resistance) 2

   • Amoxicillin
   • Lansoprazole

Treatment Selection Algorithm

1. Assess regional clarithromycin resistance patterns:

   • If resistance >15-20%: Use bismuth quadruple therapy
   • If resistance <15-20%: Standard triple therapy is acceptable

2. Consider patient factors:

   • Previous antibiotic exposure history
   • Medication allergies (especially to clarithromycin or penicillin)
   • Comorbidities affecting medication metabolism

3. Administer PPI properly:

   • Give 30 minutes before eating on an empty stomach
   • Avoid concomitant H2 receptor antagonists 1

Second-Line Treatment Options

After failure of first-line therapy, consider:

1. Bismuth quadruple therapy (if not used initially) 1
2. Levofloxacin-based triple therapy 1
3. Rifabutin-based triple therapy (for refractory cases) 1, 3
4. High-dose dual therapy (for refractory cases) 1

Important Clinical Considerations

Confirmation of Eradication

• Wait at least 4 weeks after completing antibiotics 1
• Use Urea Breath Test (sensitivity 95%, specificity 90%) or monoclonal stool antigen test 1

Common Pitfalls to Avoid

• Inadequate treatment duration: 14-day regimens are superior to 7-day regimens, improving eradication by approximately 5% 1
• Poor medication adherence: Explain the importance of completing the full course
• Improper PPI timing: Ensure PPI is taken 30 minutes before meals 1
• Ignoring antibiotic history: Previous antibiotic exposure increases resistance risk 1
• Failure to confirm eradication: Always test to confirm successful treatment 1, 3

Special Populations

• Pregnancy: Avoid invasive diagnostic procedures unless absolutely necessary; if needed, perform in second trimester 1
• Breastfeeding: Most H. pylori medications are compatible 1

Supportive Measures

Dietary Management

• Low in acidic, spicy, and fatty foods
• Regular consumption of fruits and vegetables rich in vitamin C 1

Lifestyle Modifications

• Eat smaller, more frequent meals
• Avoid eating within 3 hours of bedtime
• Stay hydrated with water throughout the day 1

The most recent American College of Gastroenterology guidelines (2024) reinforce bismuth quadruple therapy for 14 days as the preferred regimen when antibiotic susceptibility is unknown, with rifabutin triple therapy as a suitable alternative for patients without penicillin allergy 3. This approach is designed to maximize eradication rates while minimizing the impact of increasing antibiotic resistance.