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

Treatment for Helicobacter pylori Infection

Bismuth quadruple therapy for 14 days is the preferred first-line treatment for H. pylori infection in regions with high clarithromycin resistance (>15-20%). 1

First-Line Treatment Options

The selection of appropriate therapy should be based on regional antibiotic resistance patterns:

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

   • Bismuth quadruple therapy (14 days): PPI + bismuth + tetracycline + metronidazole
     • Eradication rate: approximately 85% 1
   • Alternative: Concomitant non-bismuth quadruple therapy (14 days): PPI + clarithromycin + amoxicillin + metronidazole
     • Eradication rate: approximately 80% 1

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

   • Standard triple therapy (14 days): PPI + amoxicillin + clarithromycin
     • Eradication rate: approximately 85% 1
   • FDA-approved regimen includes amoxicillin + clarithromycin + lansoprazole (triple therapy) 2

Second-Line Treatment Options

If first-line therapy fails, the following options are recommended:

• After failure of clarithromycin-based therapy:

  • Bismuth quadruple therapy (if not used initially)
  • Levofloxacin-based triple therapy 1

• For refractory cases with two failed therapies:

  • Rifabutin-based triple therapy
  • High-dose dual therapy 1

Treatment Duration and Administration

• 14-day regimens are recommended over 7-day regimens (improves eradication success by approximately 5%) 1
• PPI should be taken 30 minutes before meals on an empty stomach 1
• Avoid concomitant use of other antacids (e.g., H2 receptor antagonists) 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

Post-Treatment Testing

• 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 1

Special Considerations

Penicillin Allergy

• For patients with penicillin allergy, bismuth quadruple therapy is preferred as it doesn't contain amoxicillin 1, 3

Pregnancy

• Avoid invasive diagnostic procedures during pregnancy unless absolutely necessary
• If needed, perform preferably in the second trimester 1

Breastfeeding

• Most medications used for H. pylori treatment are compatible with breastfeeding 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: 14-day regimens are superior to 7-day regimens 1
2. Ignoring antibiotic resistance patterns: Regional resistance patterns should guide therapy selection 1, 4
3. Premature post-treatment testing: Wait at least 4 weeks after therapy completion 1
4. Repeating failed regimens: After failure of clarithromycin-based therapy, avoid using clarithromycin again unless susceptibility is confirmed 1, 4
5. Poor patient adherence: Thoroughly explain the importance of completing the full course of treatment 1

Dietary and Lifestyle Management During Treatment

• Diet low in acidic, spicy, and fatty foods
• Regular consumption of fruits and vegetables rich in vitamin C
• Smaller, more frequent meals
• Avoid eating within 3 hours of bedtime
• Stay hydrated with water throughout the day 1

The American College of Gastroenterology's 2024 guideline reinforces that bismuth quadruple therapy for 14 days is the preferred regimen when antibiotic susceptibility is unknown, which aligns with the American Gastroenterological Association's recommendations 3, 1.