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

Treatment Plan for H. 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 Treatment:

• Bismuth quadruple therapy (14 days) 1
  • Components typically include:
    • Proton pump inhibitor (PPI) standard dose twice daily
    • Bismuth subsalicylate/subcitrate
    • Tetracycline
    • Metronidazole

Alternative First-Line Options:

1. Concomitant non-bismuth quadruple therapy (14 days) - approximately 80% eradication rate 1

   • PPI + amoxicillin + clarithromycin + metronidazole

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

   • PPI + amoxicillin (1g twice daily) + clarithromycin (500mg twice daily) 2

Second-Line Treatment Options

If first-line therapy fails, second-line treatment should avoid previously used antibiotics 1:

• After bismuth quadruple therapy failure:

  • Levofloxacin-based triple therapy for 10-14 days 1, 3

• After clarithromycin-based therapy failure:

  • Bismuth quadruple therapy for 14 days 1, 4

Third-Line Treatment Options

For patients who have failed two previous treatment attempts:

• Rifabutin-based triple therapy (10 days) 1, 5

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

• High-dose dual therapy (14 days) 1, 6

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

Diagnostic Testing

• Before treatment: 13C urea breath test or monoclonal stool antigen test (sensitivity and specificity >90%) 1
• Post-treatment confirmation: Wait at least 4 weeks after completing antibiotic therapy before testing for H. pylori eradication 1

Special Considerations

Penicillin Allergy

• For patients with true penicillin allergy, use bismuth quadruple therapy with tetracycline instead of amoxicillin 1
• PPI-tetracycline-metronidazole is an effective alternative 1

Antibiotic Resistance

• Increasing resistance to clarithromycin, levofloxacin, and metronidazole is a major cause of treatment failure 1, 6
• Previously used antibiotics should be avoided in subsequent eradication attempts 1
• Local antibiotic resistance patterns should guide therapy selection when available 1, 5

Dietary and Lifestyle Management

• Diet low in acidic, spicy, and fatty foods is recommended 1
• Regular consumption of fruits and vegetables rich in vitamin C 1
• Eating smaller, more frequent meals and avoiding eating within 3 hours of bedtime 1
• Staying hydrated with water throughout the day 1

Treatment Administration Guidelines

• Amoxicillin should be taken at the start of a meal to minimize gastrointestinal intolerance 2
• Treatment should be continued for the full prescribed duration to ensure complete eradication 2
• Patients with severe renal impairment (GFR <30 mL/min) require dosage adjustments 2

Monitoring and Follow-up

• Confirm eradication with urea breath test or stool antigen test 4-8 weeks after therapy completion 1, 3
• Surveillance endoscopy should be performed every 3 years in patients with risk factors for gastric cancer or atrophic gastritis 1
• Patients aged ≥55 or with alarm symptoms should be referred for prompt endoscopy with H. pylori testing 1

The increasing prevalence of antibiotic resistance highlights the importance of following evidence-based treatment regimens and confirming eradication after treatment completion. Bismuth-containing regimens have become increasingly important as first-line therapy due to their effectiveness against resistant strains 1, 5.