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

Treatment for H. pylori Infection

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 for 14 days (85% eradication rate) 1
   • Components: PPI + bismuth + tetracycline + metronidazole

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

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

3. Alternative first-line option:

   • Concomitant non-bismuth quadruple therapy for 14 days (80% eradication rate) 1
   • Components: PPI + clarithromycin + amoxicillin + metronidazole

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, 2
• High-dose dual therapy 1

Important Clinical Considerations

Antibiotic Resistance Testing

• After two failed therapies with confirmed patient adherence, H. pylori susceptibility testing should guide subsequent regimen selection 1
• Clarithromycin resistance cannot be overcome by increasing dose or duration 3
• Metronidazole resistance can often be overcome by increasing dose and duration of treatment with acid suppression 3

PPI Administration

• Optimal PPI dosing is 30 minutes prior to eating or drinking on an empty stomach 1
• Avoid concomitant use of other antacids (e.g., H2 receptor antagonists) 1

FDA-Approved Regimens

For adult patients with H. pylori infection and duodenal ulcer disease:

• Triple therapy: Amoxicillin + clarithromycin + lansoprazole 4
• Dual therapy: Amoxicillin + lansoprazole (for patients allergic/intolerant to clarithromycin or with suspected/known clarithromycin resistance) 4

Confirmation of Eradication

• 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 (95% sensitivity, 90% specificity) 1
• Monoclonal stool antigen test is an acceptable alternative 1

Treatment Duration

• 14-day regimens are recommended for all treatment options 1
• Extending treatment from 7 to 14 days improves eradication success by approximately 5% 1

Common Pitfalls and Caveats

1. Antibiotic history: Review the patient's previous antibiotic exposure before selecting a treatment regimen to avoid using antibiotics where resistance may have developed 1

2. Clarithromycin resistance: Do not use clarithromycin-based regimens for retreatment when initial clarithromycin-based therapy has failed 2

3. Treatment adherence: Poor adherence is a major cause of treatment failure. Ensure patients understand the importance of completing the full course of therapy 1

4. Timing of eradication testing: Testing too soon after treatment completion may lead to false-negative results 1

5. Dietary considerations: Advise patients to avoid acidic, spicy, and fatty foods during treatment to prevent irritation of the gastric lining 1

The evidence strongly supports the use of bismuth quadruple therapy as first-line treatment in most regions due to increasing clarithromycin resistance worldwide, with 14-day regimens providing the highest eradication rates 1, 2.