What are the treatment options for resistant Helicobacter pylori (H. pylori) infection?

From the Guidelines

For resistant H. pylori infections, a quadruple therapy regimen is recommended as the first-line treatment, as it has been shown to be effective in achieving high eradication rates, even in areas with high antibiotic resistance rates 1. This typically includes a proton pump inhibitor (such as esomeprazole 40mg twice daily), bismuth subsalicylate (525mg four times daily), tetracycline (500mg four times daily), and metronidazole (500mg three times daily) for 14 days. Some key points to consider when treating resistant H. pylori infections include:

• The increasing resistance of H. pylori to antibiotic therapy necessitates local availability of susceptibility tests for individuals, and establishment of regional and national monitoring programs to develop evidence-based locally relevant eradication strategies 1.
• If the initial quadruple therapy regimen fails, alternative regimens include levofloxacin-based triple therapy (PPI, amoxicillin 1g twice daily, and levofloxacin 500mg once daily for 14 days) or rifabutin-based triple therapy (PPI, amoxicillin 1g twice daily, and rifabutin 150mg twice daily for 10-14 days) 1.
• Culture and antibiotic susceptibility testing should be considered before selecting a rescue therapy, especially if the patient requires endoscopy for diagnostic assessment 1.
• Patients should avoid alcohol during treatment due to potential interactions with metronidazole, take medications as prescribed even if symptoms improve, and complete the full course of therapy.
• Treatment success should be confirmed with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and while off PPI therapy for at least 2 weeks. It is essential to note that the choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community, and that individual susceptibility testing is generally only advised after second-line treatment failure due to cost and logistics 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 options for resistant Helicobacter pylori (H. pylori) infection are:

• Dual therapy: Amoxicillin in combination with lansoprazole for patients who are allergic or intolerant to clarithromycin or in whom resistance to clarithromycin is known or suspected 2. Note that the label does not provide information on treatment options for resistance to amoxicillin itself.

From the Research

Treatment Options for Resistant H. pylori Infection

• The treatment of resistant H. pylori infection often requires a combination of medications, including proton pump inhibitors (PPIs), antibiotics, and bismuth-based therapies 3, 4, 5, 6, 7.
• First-line treatment options may include:
  • 14-day therapies with clarithromycin-amoxicillin-bismuth and metronidazole-tetracycline-bismuth, both with high-dose PPIs 3.
  • 10-day quadruple therapies with clarithromycin-amoxicillin-bismuth, metronidazole-tetracycline-bismuth, and clarithromycin-amoxicillin-metronidazole (sequential), all with standard-dose PPIs 3.
• Second-line treatment options may include:
  • Metronidazole-tetracycline-bismuth quadruple therapy for 14- and 10-days with standard and high-dose PPIs, respectively 3.
  • Levofloxacin-amoxicillin triple therapy for 14-days with high-dose PPIs 3.
  • Ten-day PPI-bismuth-tetracycline-levofloxacin quadruple therapy, which has been shown to be more effective than standard levofloxacin triple therapy in the second-line treatment of H. pylori infection 7.
• Alternative salvage therapies, such as Proton pump inhibitor, Amoxicillin, Rifabutin, and Ciprofloxacin (PARC) or Proton pump inhibitor, Bismuth subcitrate, Rifabutin, and Ciprofloxacin (PBRC), may also be effective in treating resistant H. pylori infection, especially in patients with penicillin allergy 4.
• The choice of treatment should be based on the patient's specific needs and medical history, as well as the presence of antibiotic resistance 4, 5, 6, 7.