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

Recommended Treatment Regimens for H. pylori Infection

The first-line treatment for H. pylori infection should be bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline) for 14 days in regions with high clarithromycin resistance (>15-20%), or standard triple therapy (PPI + clarithromycin + amoxicillin) for 14 days in regions with low clarithromycin resistance (<15-20%). 1

First-Line Treatment Options

Bismuth Quadruple Therapy (Preferred in High Clarithromycin Resistance Areas)

• PPI standard dose twice daily
• Bismuth ~300mg four times daily
• Metronidazole 500mg three times daily
• Tetracycline 500mg four times daily
• Duration: 14 days
• Eradication rate: approximately 85% 1

Concomitant Non-Bismuth Quadruple Therapy (Alternative First-Line)

• PPI standard dose twice daily
• Clarithromycin 500mg twice daily
• Amoxicillin 1g twice daily
• Metronidazole or tinidazole 500mg twice daily
• Duration: 14 days
• Eradication rate: approximately 80% 1

Standard Triple Therapy (For Low Clarithromycin Resistance Areas)

• PPI standard dose twice daily
• Clarithromycin 500mg twice daily
• Amoxicillin 1g twice daily
• Duration: 14 days
• Eradication rate: approximately 85% 1

Important Administration Considerations

• PPI should be taken 30 minutes before eating on an empty stomach
• Avoid concomitant use of other antacids (e.g., H2 receptor antagonists) 2
• To minimize gastrointestinal intolerance, amoxicillin should be taken at the start of a meal 3

Second-Line Treatment Options

After Failure of Clarithromycin-Based Therapy

• Bismuth quadruple therapy (as described above) for 14 days 2

After Failure of Bismuth Quadruple Therapy

• Levofloxacin-based triple therapy:
  • PPI standard dose twice daily
  • Levofloxacin 500mg once daily
  • Amoxicillin 1g twice daily
  • Duration: 14 days 2

Treatment for Refractory Cases

After Two Failed Therapies

• H. pylori susceptibility testing should be performed to guide subsequent regimen selection 2
• Options include:
  • Rifabutin triple therapy: Rifabutin 150-300mg daily, amoxicillin 1g twice daily, PPI standard dose twice daily for 10 days 2
  • High-dose dual therapy: Amoxicillin 2-3g daily in 3-4 split doses, high-dose PPI twice daily for 14 days 2

Special Considerations

Penicillin Allergy

• For patients with true penicillin allergy, alternative regimens should be used:
  • Bismuth quadruple therapy (as described above)
  • PPI + bismuth + levofloxacin + tetracycline for 14 days 2

Renal Impairment

• For patients with severe renal impairment (GFR 10-30 mL/min): 500mg or 250mg amoxicillin every 12 hours
• For patients with very severe renal impairment (GFR <10 mL/min): 500mg or 250mg amoxicillin every 24 hours 3

Verification of Eradication

• Wait at least 4 weeks after completing antibiotic therapy before testing for H. pylori eradication 1
• Urea Breath Test (UBT) or monoclonal stool antigen test are recommended for confirmation of eradication 1

Common Pitfalls and Caveats

1. Inadequate treatment duration: All H. pylori eradication regimens should now be given for 14 days to improve success rates 2, 4

2. Ignoring local resistance patterns: Treatment selection should be based on regional antibiotic resistance patterns, particularly for clarithromycin 1

3. Poor medication adherence: Emphasize the importance of completing the full course of therapy to achieve successful eradication

4. Improper PPI timing: Optimal PPI dosing is 30 minutes prior to eating on an empty stomach 2

5. Unproven adjunctive therapies: Probiotics are of unproven benefit for refractory H. pylori infection and should be considered experimental 2

6. Failure to test for eradication: Confirmation of eradication is essential, particularly in high-risk patients or those with persistent symptoms

By following this evidence-based approach to H. pylori treatment, clinicians can maximize eradication success while minimizing antibiotic resistance development.