Treatment of Helicobacter pylori Infection
Bismuth quadruple therapy for 14 days is the preferred first-line treatment for H. pylori infection when antibiotic susceptibility is unknown, with an eradication rate of 85%. 1
First-Line Treatment Options
The following regimens are recommended based on their eradication rates:
Bismuth quadruple therapy (14 days) - 85% eradication rate 1
- Components: Proton pump inhibitor + Bismuth + Tetracycline + Metronidazole
Concomitant non-bismuth quadruple therapy (14 days) - 80% eradication rate 1
- Components: Proton pump inhibitor + Amoxicillin + Clarithromycin + Metronidazole
Standard triple therapy (14 days) - 85% eradication rate 1
- Components: Proton pump inhibitor + Amoxicillin + Clarithromycin
Note: Standard triple therapy should only be used in regions with low clarithromycin resistance rates 2. Due to increasing antimicrobial resistance, clarithromycin-containing triple therapies are declining in effectiveness and should be avoided unless susceptibility testing confirms clarithromycin sensitivity 3.
FDA-Approved Regimens
For adult patients, the FDA has approved the following H. pylori treatment options 4:
- Triple therapy: Amoxicillin + Clarithromycin + Lansoprazole
- Dual therapy: Amoxicillin + Lansoprazole (for patients allergic or intolerant to clarithromycin, or when clarithromycin resistance is suspected)
Second-Line Treatment Options
If first-line therapy fails, the following options are recommended:
Refractory Cases (After Two Failed Therapies)
For patients who have failed two treatment attempts, consider:
Diagnostic Testing
Before initiating treatment:
- Use 13C urea breath test or stool antigen test for diagnosis (sensitivity and specificity >90%) 1
- Endoscopy with biopsy is recommended for complicated cases (peptic ulcer disease, gastric ulcer, MALT lymphoma) 1
After treatment:
- Confirm eradication with urea breath test or monoclonal stool antigen test at least 4 weeks after completing therapy 1
- Wait at least 4 weeks after antibiotic therapy before testing for eradication 1
Treatment Duration and Follow-up
- All recommended regimens should be administered for 14 days to maximize eradication rates 1, 5
- Confirmation of eradication is recommended, particularly in patients with increased risk of gastric cancer 1
- If symptoms persist despite eradication, consider switching from PPI to prokinetic agent for bloating/fullness symptoms 1
Special Considerations
- Antibiotic resistance: The key factor for treatment failure is antibiotic resistance, particularly to clarithromycin and metronidazole 3, 6
- Susceptibility testing: When available, antibiotic susceptibility testing should guide treatment selection, especially after treatment failure 5
- Regional variations: Treatment success varies by geographic region, with some regimens showing better results in specific populations 7
Dietary and Lifestyle Recommendations
- Diet low in acidic, spicy, and fatty foods 1
- Regular consumption of fruits and vegetables rich in vitamin C 1
- Eating smaller, more frequent meals 1
- Avoiding eating within 3 hours of bedtime 1
- Staying hydrated throughout the day 1
- Regular aerobic exercise for patients with persistent symptoms 1
Common Pitfalls to Avoid
- Using clarithromycin-containing regimens in areas with high clarithromycin resistance 3
- Insufficient treatment duration (shorter than 14 days) 1, 7
- Using dual therapy when triple or quadruple therapy would be more effective 7
- Failing to confirm eradication, especially in high-risk patients 1
- Not considering antibiotic exposure history when selecting treatment regimens 1
The treatment landscape for H. pylori is evolving due to increasing antibiotic resistance. Bismuth quadruple therapy has emerged as the most reliable empiric first-line option, while susceptibility-guided treatment represents the ideal approach when feasible 3, 5.