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

Treatment of 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, with an eradication rate of approximately 85%. 1

First-Line Treatment Options

Preferred First-Line Regimen

• Bismuth quadruple therapy (14 days) 1
  • PPI (standard dose twice daily)
  • Bismuth subsalicylate/subcitrate
  • Metronidazole
  • Tetracycline

Alternative First-Line Options

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

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

2. Triple therapy (14 days) - only in areas with low clarithromycin resistance 1

   • PPI (standard dose twice daily)
   • Clarithromycin
   • Amoxicillin or metronidazole
   • Eradication rate: approximately 85% in susceptible populations

3. FDA-approved regimens 2

   • Triple therapy: 1g amoxicillin, 500mg clarithromycin, and 30mg lansoprazole, all given twice daily for 14 days
   • Dual therapy: 1g amoxicillin and 30mg lansoprazole, each given three times daily for 14 days (for patients allergic/intolerant to clarithromycin or with suspected resistance)

Second-Line Treatment Options

If first-line therapy fails, the choice of second-line therapy should avoid antibiotics previously used 1:

1. If bismuth quadruple therapy fails:

   • Levofloxacin-based triple therapy for 10-14 days
     • PPI (standard dose twice daily)
     • Amoxicillin
     • Levofloxacin

2. If clarithromycin-based therapy fails:

   • Bismuth quadruple therapy for 14 days

Salvage Treatment Options (After Two Failed Attempts)

1. Rifabutin-based triple therapy (10 days) 1

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

2. High-dose dual therapy (14 days) 1

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

Special Considerations

Penicillin Allergy

• For patients with true penicillin allergy, bismuth quadruple therapy with tetracycline instead of amoxicillin is recommended 1
• Alternative regimens using levofloxacin or bismuth-based therapies should be considered

Antibiotic Resistance

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

Testing for Eradication

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

Endoscopy Indications

• Patients aged ≥55 or with alarm symptoms should be referred for prompt endoscopy with H. pylori testing 1
• Surveillance endoscopy should be performed every 3 years in patients with risk factors for gastric cancer or atrophic gastritis

Dietary and Lifestyle Management

• Diet low in acidic, spicy, and fatty foods is recommended
• Regular consumption of fruits and vegetables rich in vitamin C
• Eating smaller, more frequent meals and avoiding eating within 3 hours of bedtime
• Staying hydrated with water throughout the day

The 14-day duration for all treatment regimens is crucial, as the American Gastroenterological Association strongly recommends this treatment duration to maximize eradication rates 1. The choice between first-line options should be guided by local resistance patterns when available, with bismuth quadruple therapy being the most reliable option when antibiotic susceptibility is unknown.