What are the recommended H pylori (Helicobacter pylori) eradication regimens in India?

H. pylori Eradication Regimens in India

Bismuth quadruple therapy for 14 days is the preferred first-line treatment regimen for H. pylori infection in India when antibiotic susceptibility is unknown, with an eradication rate of approximately 85%. 1

First-Line Treatment Options

Preferred Regimen

• Bismuth quadruple therapy (14 days):
  • Bismuth subcitrate 120 mg four times daily
  • Tetracycline 500 mg four times daily
  • Metronidazole 400-500 mg three times daily
  • Proton pump inhibitor (PPI) standard dose twice daily
  • Eradication rate: approximately 85% 1

Alternative First-Line Options

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

   • PPI standard dose twice daily
   • Amoxicillin 1g twice daily
   • Clarithromycin 500 mg twice daily
   • Metronidazole 400-500 mg twice daily
   • Eradication rate: approximately 80% 1

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

   • PPI standard dose twice daily
   • Amoxicillin 1g twice daily
   • Clarithromycin 500 mg twice daily
   • Eradication rate: approximately 85% 1, 2

Second-Line Treatment Options

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

1. If bismuth quadruple therapy fails:

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

2. If clarithromycin-based therapy fails:

   • Bismuth quadruple therapy for 14 days 1

Rescue Therapy Options

For patients who have failed two previous treatment attempts:

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

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

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

   • Amoxicillin 2-3g daily in 3-4 split doses
   • PPI high-dose twice daily 1

Important Considerations for India

• Local antibiotic resistance patterns should guide therapy selection when available 1
• Increasing resistance to clarithromycin, levofloxacin, and metronidazole is a major cause of treatment failure in many regions 1, 3
• Earlier studies in India showed moderate success rates with traditional regimens:
  • A 1999 study showed eradication rates of only 59-70% with various triple therapy regimens 4
  • This highlights the need for more aggressive quadruple therapy approaches in current practice

Confirmation of Eradication

• Urea Breath Test (UBT) is the gold standard non-invasive test (sensitivity 95%, specificity 90%) 1
• Monoclonal stool antigen test is an acceptable alternative 1
• Testing should be performed at least 4 weeks after completing antibiotic therapy 1

Special Situations

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 therapy 1

Treatment Duration

• 14-day regimens are preferred over 7-day or 10-day regimens for most combinations 1, 5
• Longer duration therapy significantly increases eradication rates, particularly for PPI-clarithromycin-amoxicillin regimens 5

The evidence clearly supports using bismuth quadruple therapy as first-line treatment in India, where antibiotic resistance patterns may limit the effectiveness of traditional triple therapy regimens.