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

From the Guidelines

The current recommended first-line regimen for Helicobacter pylori infection is bismuth quadruple therapy, consisting of a proton pump inhibitor (PPI) such as omeprazole 20mg twice daily, bismuth 300mg four times daily, tetracycline 500mg four times daily, and metronidazole 500mg three times daily for 14 days, as this regimen has been shown to offer higher eradication rates (>90%) compared to traditional triple therapy 1. This recommendation is based on the most recent and highest quality study, which suggests that bismuth quadruple therapy has largely replaced the traditional triple therapy due to increasing antibiotic resistance. Some key points to consider when treating H. pylori infection include:

• The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community 1.
• Alternative regimens include non-bismuth quadruple therapy (concomitant therapy) with a PPI, amoxicillin 1g, clarithromycin 500mg, and metronidazole 500mg, all twice daily for 14 days.
• For patients with penicillin allergy, a regimen of PPI, bismuth, tetracycline, and metronidazole is recommended.
• Treatment success should be confirmed with a urea breath test, stool antigen test, or endoscopic testing at least 4 weeks after completing therapy and after PPI discontinuation for at least 2 weeks. It's worth noting that the worldwide prevalence of H. pylori infections is approximately 50%, with the highest being in developing countries, and standard treatments have been endorsed by Western scientific societies and regulatory authorities relying on clarithromycin, metronidazole, or amoxicillin in conjunction with PPI 1. However, as the response to eradication therapy is significantly related to the prevalence of primary resistance in the population, it's essential to consider the underlying prevalence of resistant strains in the community when choosing a treatment regimen. In general, the recommended doses for PPI are standard dose twice a day, and the doses for other medications such as clarithromycin, amoxicillin, and metronidazole are also specified in the guidelines 1.

From the FDA Drug Label

Adult Patients only Helicobacter pylori Infection and Duodenal Ulcer Disease: Triple therapy for Helicobacter pylori (H. pylori) with clarithromycin and lansoprazole : Amoxicillin, in combination with clarithromycin plus lansoprazole as triple therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) to eradicate H. pylori. Dual therapy for H. pylori with lansoprazole : Amoxicillin, in combination with lansoprazole delayed-release capsules as dual therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) who are either allergic or intolerant to clarithromycin or in whom resistance to clarithromycin is known or suspected.

The new treatment regimen for Helicobacter pylori (H. pylori) infection is:

• Triple therapy: Amoxicillin, clarithromycin, and lansoprazole
• Dual therapy: Amoxicillin and lansoprazole (for patients allergic or intolerant to clarithromycin or with known/suspected resistance to clarithromycin) 2

From the Research

New Treatment Regimen for H. pylori Infection

The new treatment regimen for Helicobacter pylori (H. pylori) infection involves several options, including:

• Concomitant nonbismuth quadruple therapy (proton pump inhibitor [PPI] + amoxicillin + metronidazole + clarithromycin [PAMC]) for 14 days 3
• Traditional bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline [PBMT]) for 14 days 3, 4
• PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole) for 14 days, restricted to areas with known low clarithromycin resistance or high eradication success with these regimens 3, 5
• Levofloxacin-containing therapy (PPI + amoxicillin + levofloxacin) for 14 days as a rescue therapy 3, 6
• Rifabutin regimens, restricted to patients who have failed to respond to at least 3 prior options 3

Second-Line Treatment Options

Second-line treatment options for H. pylori infection include:

• Bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline) 4, 6
• Levofloxacin-containing triple therapy (PPI + amoxicillin + levofloxacin) 5, 6
• Tetracycline-levofloxacin quadruple therapy (PPI + bismuth + tetracycline + levofloxacin) 6
• High-dose dual PPI-amoxicillin therapy 6
• Levofloxacin-based sequential quadruple therapy 6
• Potassium-competitive acid blocker-based regimens 6

Treatment Duration and Antibiotic Resistance

The treatment duration for H. pylori infection is recommended to be 14 days 3, 4, 5 The choice of H. pylori eradication regimen should be based on the local prevalence of clarithromycin resistance and the previous use of macrolides 4, 5 Antibiotic resistance is a major concern in the treatment of H. pylori infection, and the use of levofloxacin-amoxicillin triple therapy is limited by the rising prevalence of levofloxacin-resistant strains 6