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

H. pylori Treatment Protocol

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

Based on Regional Antibiotic Resistance:

1. High Clarithromycin Resistance Regions (>15-20%):

   • Bismuth quadruple therapy (14 days, 85% eradication rate) 1:

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

   • Alternative: Concomitant non-bismuth quadruple therapy (14 days, 80% eradication rate) 1:

     • PPI
     • Clarithromycin
     • Amoxicillin
     • Metronidazole

2. Low Clarithromycin Resistance Regions (<15-20%):

   • Standard triple therapy (14 days, 85% eradication rate) 1:
     • PPI
     • Amoxicillin
     • Clarithromycin

Specific FDA-Approved Regimens:

• Triple therapy 2:

  • Amoxicillin 1g twice daily
  • Clarithromycin 500mg twice daily
  • Lansoprazole 30mg twice daily
  • Duration: 14 days

• Dual therapy 2:

  • Amoxicillin 1g three times daily
  • Lansoprazole 30mg three times daily
  • Duration: 14 days

PPI Administration

• Take PPI 30 minutes before eating or drinking on an empty stomach
• Avoid concomitant use of other antacids (e.g., H2 receptor antagonists) 1

Second-Line Treatment Options

After failure of first-line therapy:

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

For refractory cases with two failed therapies:

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

Treatment Selection Algorithm

1. Assess regional clarithromycin resistance patterns
2. Review patient's antibiotic exposure history
3. Consider patient-specific factors:
   • Penicillin allergy: Avoid amoxicillin-containing regimens 4
   • QTc prolongation risk: Avoid clarithromycin 4
   • Pregnancy/breastfeeding: Most medications are compatible with breastfeeding, but consult guidelines for pregnancy 1

Post-Treatment Follow-Up

• Wait at least 4 weeks after completing antibiotics before testing for eradication 1
• Preferred testing method: Urea Breath Test (UBT) or monoclonal stool antigen test 1
• Endoscopy with biopsy for specific clinical scenarios (complicated peptic ulcer disease, gastric ulcer, MALT lymphoma) 1

Common Pitfalls and Caveats

• Inadequate treatment duration: 14-day regimens are superior to 7-day regimens (5% higher eradication rate) 1
• Poor medication adherence: Emphasize the importance of completing the full course
• Antibiotic resistance: Consider susceptibility testing after two failed therapies 1, 3
• Medication timing: Improper PPI timing reduces efficacy 1
• Side effects management: Common side effects include diarrhea, rash, vomiting, and nausea 2

Special Considerations

• Elderly patients: May require dose adjustments based on renal function 4
• Renal impairment: Reduce amoxicillin dose in patients with severe renal impairment (GFR >30 mL/min) 2
• Drug interactions:
  • Probenecid is not recommended with amoxicillin 2
  • Amoxicillin may reduce oral contraceptive efficacy 2
  • Allopurinol with amoxicillin increases rash risk 2
  • Monitor anticoagulant therapy as amoxicillin may increase prothrombin time 2

The most recent evidence from the American College of Gastroenterology (2024) strongly supports bismuth quadruple therapy for 14 days as the preferred regimen when antibiotic susceptibility is unknown 3, aligning with the recommendations from the American Gastroenterological Association 1.