From the Guidelines
The recommended quadruple therapy regimen for Helicobacter pylori (H. pylori) infection is bismuth quadruple therapy, consisting of a proton pump inhibitor (PPI), bismuth, metronidazole, and tetracycline, for 14 days.
Key Components of the Regimen
- PPI: The dose depends on the specific PPI used, with standard doses including dexilant 30 mg, esomeprazole 20 mg, lansoprazole 30 mg, omeprazole 20 mg, pantoprazole 40 mg, and rabeprazole 20 mg 1.
- Bismuth: The dose depends on the formulation used, with examples including bismuth subsalicylate (262 mg) and colloidal bismuth subcitrate 120 mg 1.
- Metronidazole: 400 mg four times a day or 500 mg three to four times a day, which may be substituted by tinidazole 1.
- Tetracycline: 500 mg four times a day 1.
Rationale for the Recommendation
The bismuth quadruple therapy is favored due to its acceptable success even in strains displaying in vitro metronidazole resistance and its ability to avoid the potential problem of antibiotic overuse 1.
Duration of Therapy
The recommended duration of the bismuth quadruple therapy is 14 days, as there is sufficient evidence of higher success with 14 days versus shorter durations 1.
From the Research
Recommended Quadruple Therapy Regimen for H. pylori Infection
The recommended quadruple therapy regimen for Helicobacter pylori (H. pylori) infection includes:
- A standard bismuth quadruple therapy, which consists of a proton pump inhibitor (PPI), bismuth, tetracycline, and metronidazole 2
- A tetracycline-levofloxacin quadruple therapy, which consists of a PPI, bismuth, tetracycline, and levofloxacin 2, 3
- An amoxicillin-levofloxacin quadruple therapy, which consists of a PPI, bismuth, amoxicillin, and levofloxacin 2
- A levofloxacin-based sequential quadruple therapy 2
- A high-dose PPI-amoxicillin dual therapy 2, 3
Duration of Quadruple Therapy
The optimal duration of quadruple therapy for H. pylori infection is:
- 10-14 days for bismuth-containing quadruple therapy 4, 5
- 10 days for concomitant nonbismuth quadruple therapy 6
- 10 days for tetracycline-levofloxacin quadruple therapy 3
Efficacy of Quadruple Therapy
The efficacy of quadruple therapy for H. pylori infection is:
- High eradication rates (above 85%) for standard bismuth quadruple therapy, tetracycline-levofloxacin quadruple therapy, and high-dose PPI-amoxicillin dual therapy 2, 4, 3
- Lower eradication rates for levofloxacin-amoxicillin triple therapy, especially in areas with high fluoroquinolone resistance 2, 3