What are the current Indian guidelines for starting H pylori (Helicobacter pylori) eradication?

Current Indian Guidelines for H. pylori Eradication

Bismuth quadruple therapy for 14 days is the recommended first-line treatment for H. pylori eradication in India due to high clarithromycin resistance. 1

First-Line Treatment Options

The current guidelines recommend the following regimens based on regional antibiotic resistance patterns:

1. High clarithromycin resistance regions (>15-20%, which includes most of India):

   • Bismuth quadruple therapy (PPI + bismuth + tetracycline + metronidazole) for 14 days (eradication rate ~85%) 1
   • Concomitant non-bismuth quadruple therapy (PPI + clarithromycin + amoxicillin + metronidazole) for 14 days as an alternative (eradication rate ~80%) 1

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

   • Standard triple therapy (PPI + amoxicillin + clarithromycin) for 14 days 1

Treatment Duration and Dosing

• 14-day treatment duration is recommended for all regimens, as extending treatment from 7 to 14 days improves eradication success by approximately 5% 1
• For H. pylori eradication with triple therapy, the FDA-approved dosing is:
  • Amoxicillin 1 gram twice daily
  • Clarithromycin 500 mg twice daily
  • PPI (e.g., lansoprazole 30 mg) twice daily 2

Second-Line Treatment Options

After failure of first-line therapy:

• Bismuth quadruple therapy (if not used as first-line)
• Levofloxacin-based triple therapy 1

For refractory cases with two failed therapies:

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

Diagnostic Testing

• Pre-treatment diagnosis: Urea Breath Test (UBT) or monoclonal stool antigen test (sensitivity 95%, specificity 90%) 1
• Post-treatment confirmation: Wait at least 4 weeks after completing antibiotics before testing for eradication 1
• Endoscopy with biopsy: Recommended for complicated peptic ulcer disease, gastric ulcer, MALT lymphoma, or when histological assessment is needed 1

Important Clinical Considerations

• Antibiotic resistance testing: After two failed therapies with confirmed patient adherence, H. pylori susceptibility testing should guide subsequent treatment 1
• PPI administration: Take 30 minutes before meals on an empty stomach; avoid concomitant antacids 1
• Patient history: Review antibiotic exposure history before selecting a treatment regimen 1

Pitfalls and Caveats

• Traditional clarithromycin-based triple therapy has shown only moderate success in India, with eradication rates of 68-70% 3
• Antibiotic resistance, particularly to clarithromycin and metronidazole, is the major reason for H. pylori treatment failure 4
• Some studies suggest PPI-metronidazole-amoxicillin combinations may be more effective than PPI-clarithromycin-amoxicillin in regions with high clarithromycin resistance 5
• Compliance is critical for successful eradication; patients should be educated about the importance of completing the full course of treatment

Follow-Up and Surveillance

• Surveillance endoscopy should be performed every 3 years in patients with risk factors for gastric cancer or atrophic gastritis 1
• Patients aged ≥55 or with alarm symptoms should be referred for prompt endoscopy with H. pylori testing 1