What is the recommended first-line therapy for H pylori (Helicobacter pylori) eradication?

First-Line Therapy for H. pylori Eradication

Bismuth quadruple therapy for 14 days is the recommended first-line therapy for H. pylori eradication, with an eradication rate of 85%. 1

Recommended First-Line Regimens

The British Society of Gastroenterology recommends the following first-line regimens for H. pylori eradication:

1. Bismuth quadruple therapy (14 days) - 85% eradication rate

   • PPI + bismuth + metronidazole + tetracycline (PBMT)

2. Concomitant non-bismuth quadruple therapy (14 days) - 80% eradication rate

   • PPI + amoxicillin + metronidazole + clarithromycin (PAMC)

3. Standard triple therapy (14 days) - 85% eradication rate

   • PPI + clarithromycin + amoxicillin (PCA)

Duration of Therapy

All H. pylori eradication regimens should be given for 14 days to maximize eradication rates 1. This is supported by evidence showing that increasing treatment duration from 7 to 14 days significantly increases eradication rates (from 72.9% to 81.9%) 2.

Choice of First-Line Therapy

The selection of first-line therapy should consider:

• Local antibiotic resistance patterns: Standard triple therapy should be restricted to areas with known low clarithromycin resistance 3
• Previous antibiotic exposure: A thorough review of the patient's antibiotic history is essential before selecting a treatment regimen 1
• Medication allergies: Particularly to penicillin/amoxicillin

FDA-Approved Regimens

The FDA has approved the following regimens for H. pylori eradication 4:

1. Triple Therapy: Omeprazole + clarithromycin + amoxicillin for 14 days

   • Eradication rates: 73-83% (intent-to-treat analysis)

2. Dual Therapy: Omeprazole + clarithromycin for 14 days

   • Eradication rates: 64-83% (per-protocol analysis)

Second-Line Options

If first-line therapy fails, the following options are recommended 1:

• Bismuth quadruple therapy (if not used first-line)
• Levofloxacin-based triple therapy

For refractory cases with two failed therapies, rifabutin-based triple therapy or high-dose dual therapy can be considered 1.

Diagnostic Testing

Before initiating treatment, H. pylori infection should be confirmed using:

• 13C urea breath test (sensitivity 95%, specificity 90%) or
• Monoclonal stool antigen test (equivalent accuracy) 1

Follow-Up Testing

Confirmation of eradication is recommended in patients with increased risk of gastric cancer, using the urea breath test or stool antigen test at least 4 weeks after completing antibiotic therapy 1.

Common Pitfalls to Avoid

1. Inadequate treatment duration: Using 7-day regimens instead of 14-day regimens significantly reduces eradication rates 2
2. Not considering local resistance patterns: Clarithromycin resistance significantly impacts triple therapy success 3
3. Not performing susceptibility testing after failure: The American Gastroenterological Association recommends H. pylori susceptibility testing to guide subsequent regimen selection 1
4. Testing too soon after therapy: Wait at least 4 weeks after completing antibiotic therapy before testing for eradication 1

Special Considerations

• For patients with penicillin allergy, bismuth quadruple therapy is preferred
• For patients with previous macrolide exposure, avoid clarithromycin-containing regimens
• For patients with previous treatment failure, susceptibility testing should guide therapy selection when possible 1