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

Treatment Guidelines for Helicobacter pylori Infection

Bismuth quadruple therapy for 14 days is the preferred first-line treatment regimen for H. pylori infection when antibiotic susceptibility is unknown. 1, 2, 3

First-Line Treatment Options

Preferred First-Line Therapy

• Bismuth quadruple therapy (14 days) 1, 2, 3
  • PPI (standard dose twice daily)
  • Bismuth subsalicylate/subcitrate
  • Tetracycline (500 mg four times daily)
  • Metronidazole (500 mg three to four times daily)
  • Eradication rate: approximately 85%

Alternative First-Line Options

1. Concomitant non-bismuth quadruple therapy (14 days) 1, 2

   • PPI (standard dose twice daily)
   • Amoxicillin (1g twice daily)
   • Clarithromycin (500 mg twice daily)
   • Metronidazole (500 mg twice daily)
   • Eradication rate: approximately 80%

2. Triple therapy (only in areas with low clarithromycin resistance) 1, 4

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

Second-Line Treatment Options

When first-line therapy fails, the choice of second-line therapy should avoid antibiotics previously used, particularly if treatment failure is suspected to be due to antibiotic resistance 1, 5.

Options After Failed First-Line Therapy

1. If bismuth quadruple therapy failed:

   • Levofloxacin-based triple therapy (10-14 days) 1, 6
     • PPI (standard dose twice daily)
     • Amoxicillin (1g twice daily)
     • Levofloxacin (500 mg daily)

2. If clarithromycin-based therapy failed:

   • Bismuth quadruple therapy (14 days) 1, 5

Third-Line and Rescue Therapies

For patients who have failed two previous treatment attempts, the following options are recommended:

1. Rifabutin-based triple therapy (10 days) 2, 7

   • Rifabutin (150-300 mg daily)
   • Amoxicillin (1g twice daily)
   • PPI (standard dose twice daily)

2. High-dose dual therapy (14 days) 2, 7

   • Amoxicillin (2-3g daily in 3-4 split doses)
   • PPI (high-dose twice daily)

Testing for H. pylori

Diagnostic Testing

• Non-invasive testing: 13C urea breath test or monoclonal stool antigen test (sensitivity and specificity >90%) 2
• Invasive testing: Endoscopy with biopsy (recommended for complicated peptic ulcer disease, gastric ulcer, MALT lymphoma) 2

Post-Treatment Testing

• Wait at least 4 weeks after completing antibiotic therapy before testing for H. pylori eradication 2
• Urea breath test is the gold standard for confirmation of eradication (sensitivity 95%, specificity 90%) 2

Special Considerations

Antibiotic Resistance

• Increasing resistance to clarithromycin, levofloxacin, and metronidazole is a major cause of treatment failure 1, 7
• Previously used antibiotics should be avoided in subsequent eradication attempts 1
• Local antibiotic resistance patterns should guide therapy selection when available 1, 8

Penicillin Allergy

• For patients with true penicillin allergy, alternative regimens using levofloxacin or bismuth-based therapies should be considered 2

Persistent Symptoms After Treatment

• If symptoms persist despite successful eradication, consider:
  • Continuing PPI therapy at lowest effective dose 2
  • Prokinetic agents for dysmotility-like symptoms 2
  • Tricyclic antidepressants as second-line therapy for persistent symptoms 2

Dietary Management

• Diet low in acidic, spicy, and fatty foods is recommended 2
• Regular consumption of fruits and vegetables rich in vitamin C 2
• Smaller, more frequent meals and avoiding eating within 3 hours of bedtime 2

The increasing resistance of H. pylori to antibiotics necessitates local availability of susceptibility tests and establishment of regional monitoring programs to develop evidence-based locally relevant eradication strategies 1.