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

Recommended Treatment for H. pylori Infection

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

Preferred Regimens

1. Bismuth quadruple therapy (14 days)

   • PPI + bismuth + tetracycline + metronidazole
   • Eradication rate: approximately 85%
   • Recommended in regions with high clarithromycin resistance (>15-20%)

2. Concomitant non-bismuth quadruple therapy (14 days)

   • PPI + clarithromycin + amoxicillin + metronidazole
   • Eradication rate: approximately 80%
   • Alternative first-line option

3. Standard triple therapy (14 days)

   • PPI + amoxicillin + clarithromycin
   • Eradication rate: approximately 85%
   • Only recommended in regions with low clarithromycin resistance (<15-20%)
   • FDA-approved regimen: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 2

Important: All H. pylori eradication regimens should now be given for 14 days to improve eradication success 1, 3

Second-Line Treatment Options

After failure of first-line therapy, consider:

1. Bismuth quadruple therapy (if not used as first-line)

   • PPI + bismuth + tetracycline + metronidazole for 14 days

2. Levofloxacin-based triple therapy

   • PPI + amoxicillin + levofloxacin for 14 days

Third-Line Treatment Options

For refractory cases with two failed therapies:

1. Rifabutin-based triple therapy

   • PPI + amoxicillin + rifabutin for 14 days

2. High-dose dual therapy

   • High-dose PPI + amoxicillin

Note: After two failed therapies with confirmed patient adherence, H. pylori susceptibility testing should guide subsequent regimen selection 1

Administration Guidelines

• PPI should be taken 30 minutes before eating or drinking on an empty stomach
• Avoid concomitant use of other antacids (e.g., H2 receptor antagonists)
• Amoxicillin should be taken at the start of a meal to minimize gastrointestinal intolerance 2
• For dual therapy (alternative option): 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days 2

Confirmation of Eradication

• Wait at least 4 weeks after completing antibiotic therapy before testing for H. pylori eradication
• Recommended tests:
  • Urea Breath Test (UBT) - gold standard non-invasive test (sensitivity 95%, specificity 90%)
  • Monoclonal stool antigen test - alternative with equivalent accuracy

Special Considerations

• Antibiotic resistance: Major cause of treatment failure; review patient's antibiotic exposure history before selecting a regimen
• Patient adherence: Critical for successful eradication; ensure patients understand the importance of completing the full course
• Penicillin allergy: Consider bismuth quadruple therapy without amoxicillin
• Renal impairment: Patients with GFR <30 mL/min should NOT receive the 875 mg dose of amoxicillin 2

Common Pitfalls to Avoid

1. Using standard triple therapy in areas with high clarithromycin resistance
2. Prescribing shorter treatment courses (7-10 days instead of 14 days)
3. Failing to confirm eradication after treatment
4. Repeating the same regimen after initial treatment failure
5. Not considering antibiotic resistance patterns when selecting therapy

The treatment landscape for H. pylori has evolved significantly due to increasing antibiotic resistance, making traditional triple therapy less effective in many regions. Quadruple therapies should now play a more prominent role in eradication efforts 3, 4, 5.