From the Guidelines
For resistant H. pylori infections, a quadruple therapy regimen is recommended after initial treatment failure, with bismuth quadruple therapy being the preferred approach, consisting of a proton pump inhibitor, bismuth subsalicylate, tetracycline, and metronidazole for 14 days, as supported by the most recent evidence 1.
Key Considerations
- The choice of therapy should be guided by antimicrobial susceptibility testing when available, and tailored regimens based on resistance patterns can be used.
- For clarithromycin-resistant strains, levofloxacin-based triple therapy may be effective, but its use should be limited due to rising resistance rates, as noted in the 2021 AGA clinical practice update 1.
- Rifabutin-based triple therapy is a viable option for patients with multiple treatment failures, using a proton pump inhibitor, amoxicillin, and rifabutin for 10-14 days, as recommended by the AGA clinical practice update 1.
Treatment Regimens
- Bismuth quadruple therapy: proton pump inhibitor (e.g., omeprazole 20mg twice daily), bismuth subsalicylate (525mg four times daily), tetracycline (500mg four times daily), and metronidazole (500mg three times daily) for 14 days.
- Levofloxacin-based triple therapy: proton pump inhibitor, amoxicillin (1g twice daily), and levofloxacin (500mg once daily) for 14 days, but only if the H. pylori strain is known to be sensitive to levofloxacin or if population levofloxacin resistance rates are <15% 1.
- Rifabutin-based triple therapy: proton pump inhibitor, amoxicillin (1g twice daily), and rifabutin (150mg twice daily) for 10-14 days, as a viable option for patients with multiple treatment failures 1.
Confirmation of Treatment Success
- Treatment success should be confirmed with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after therapy completion and after discontinuing proton pump inhibitors for at least 2 weeks, as recommended by the AGA clinical practice update 1.
From the FDA Drug Label
Adult Patients only Helicobacter pyloriInfection 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 pyloriinfection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) to eradicate H. pylori. Dual therapy for H. pyloriwith lansoprazole : Amoxicillin, in combination with lansoprazole delayed-release capsules as dual therapy, is indicated for the treatment of patients with H pyloriinfection 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 treatment for resistant Helicobacter pylori (H. pylori) infection is not directly addressed in the provided drug label. However, it does mention that amoxicillin can be used in combination with lansoprazole as dual therapy for patients who are either allergic or intolerant to clarithromycin or in whom resistance to clarithromycin is known or suspected.
- The dual therapy option may be considered for resistant H. pylori infection, but the label does not provide explicit guidance on the treatment of resistant H. pylori infection. 2
From the Research
Treatment Options for Resistant H. pylori Infection
- First-line treatment for H. pylori infection typically involves triple therapy with two antibiotics and a proton pump inhibitor (PPI) 3.
- However, approximately 20% of patients may fail to achieve eradication with first-line treatment, often due to antibiotic resistance or poor patient compliance 3, 4.
- In cases of treatment failure, second-line options may include bismuth-based quadruple therapy or triple therapy with levofloxacin and/or rifabutin 3, 4.
- For patients with multidrug-resistant strains, rifabutin triple therapy has been shown to be effective in achieving eradication 5.
- The Toronto Consensus recommends that all H. pylori eradication regimens be given for 14 days, and suggests concomitant nonbismuth quadruple therapy or traditional bismuth quadruple therapy as first-line options 6.
- The American College of Gastroenterology clinical practice guideline recommends bismuth quadruple therapy for 14 days as the preferred regimen for treatment-naive patients, and "optimized" bismuth quadruple therapy for treatment-experienced patients 7.
Salvage Therapies
- In cases of multiple treatment failures, salvage regimens may include clarithromycin or levofloxacin, but only if antibiotic susceptibility is confirmed 7.
- Rifabutin regimens may be restricted to patients who have failed to respond to at least three prior options 6.
- Non-antimicrobial add-on medications, such as lactoferrin or probiotics, may be used to improve eradication rates or minimize side effects in patients with multiple treatment failures 4.