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

H. pylori Treatment Recommendations

Bismuth quadruple therapy (PPI + bismuth + tetracycline + metronidazole) 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:

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

   • 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

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

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

Specific Dosing Regimens

For H. pylori eradication in adults, the FDA-approved regimens include 2:

• Triple therapy: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days
• Dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days

Important administration note: To minimize gastrointestinal intolerance, medications should be taken at the start of a meal 2

Second-Line Treatment Options

After failure of first-line therapy, consider:

• Bismuth quadruple therapy (if not used initially) 1
• Levofloxacin-based triple therapy (PPI + amoxicillin + levofloxacin) 1
• For refractory cases with two failed therapies: rifabutin-based triple therapy or 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
• A thorough review of the patient's antibiotic exposure history is essential before selecting a treatment regimen 1

Treatment Duration

All H. pylori eradication regimens should be given for 14 days to improve eradication success rates 1, 3. Extending treatment from 7 to 14 days improves eradication success by approximately 5% 1.

Post-Treatment Follow-Up

• 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 Considerations

Renal Impairment

Patients with impaired renal function may require dose adjustments:

• GFR 10-30 mL/min: 500 mg or 250 mg amoxicillin every 12 hours 2
• GFR <10 mL/min: 500 mg or 250 mg amoxicillin every 24 hours 2

Common Pitfalls to Avoid

1. Inadequate treatment duration: 14-day regimens are now strongly recommended over 7-day treatments 1, 3
2. Ignoring local resistance patterns: Treatment selection should be based on regional antibiotic resistance 1
3. Poor medication timing: PPIs should be taken 30 minutes prior to eating or drinking on an empty stomach 1
4. Concomitant antacid use: Avoid using H2 receptor antagonists during treatment 1
5. Testing too soon after treatment: Wait at least 4 weeks after completing therapy before testing for eradication 1

Dietary and Lifestyle Recommendations

• Diet low in acidic, spicy, and fatty foods
• Regular consumption of fruits and vegetables rich in vitamin C
• Eating smaller, more frequent meals
• Avoiding eating within 3 hours of bedtime
• Staying hydrated throughout the day 1

The treatment landscape for H. pylori has evolved due to increasing antibiotic resistance, making quadruple therapies increasingly important as first-line options 3, 4.