What antibiotics should be given with a Proton Pump Inhibitor (PPI) for the treatment of Helicobacter pylori infections?

Antibiotics to be Given with PPI for Helicobacter pylori Treatment

For H. pylori eradication, PPIs should be given with clarithromycin and amoxicillin or metronidazole in triple therapy, or as part of bismuth quadruple therapy with tetracycline and metronidazole in areas with high clarithromycin resistance. 1

First-Line Treatment Options Based on Clarithromycin Resistance Rates

Areas with Low Clarithromycin Resistance (<15-20%)

• PPI-Clarithromycin-Amoxicillin (PCA) Triple Therapy:
  • PPI (high-dose, twice daily) 1, 2
  • Clarithromycin 500mg twice daily 1
  • Amoxicillin 1g twice daily 3
  • Duration: 10-14 days (extends eradication success by approximately 5% compared to 7-day regimens) 1

Areas with High Clarithromycin Resistance (>15-20%)

• Bismuth-Containing Quadruple Therapy (First Choice):

  • PPI (high-dose, twice daily) 1
  • Bismuth salt
  • Tetracycline
  • Metronidazole or amoxicillin 1
  • Duration: 10-14 days

• Alternative: Sequential Treatment:

  • Days 1-5: PPI + amoxicillin
  • Days 6-10: PPI + clarithromycin + metronidazole (or tinidazole) 1

• Alternative: Non-Bismuth Quadruple (Concomitant) Therapy:

  • PPI + amoxicillin + clarithromycin + metronidazole (all given simultaneously) 1
  • Duration: 10-14 days

PPI Dosing Recommendations

• High-dose PPI (twice daily) is strongly recommended as it increases triple therapy efficacy by 6-10% compared to standard doses 1, 2
• Recommended PPI dosages for H. pylori eradication:
  • Omeprazole: 20 mg twice daily 2
  • Esomeprazole: 40 mg twice daily 2
  • Pantoprazole: 40 mg twice daily 2

Second-Line Treatment Options

After failure of PPI-clarithromycin containing therapy:

• Bismuth-containing quadruple therapy 1
• Levofloxacin-containing triple therapy (PPI + amoxicillin + levofloxacin) 1
  • Note: Consider rising rates of levofloxacin resistance 1

After failure of second-line treatment:

• Treatment should be guided by antimicrobial susceptibility testing whenever possible 1

Specific Antibiotic Regimens with PPIs

Triple Therapy with Amoxicillin

• PPI (high-dose, twice daily)
• Amoxicillin 1g twice daily
• Clarithromycin 500mg twice daily
• Duration: 14 days 3

Dual Therapy Option

• Amoxicillin 1g three times daily
• PPI (lansoprazole 30mg three times daily)
• Duration: 14 days 3

Important Considerations

• Treatment success verification: Urea breath test or validated monoclonal stool test 4-8 weeks after completion of therapy 1
• Compliance is critical: Poor adherence is a major cause of treatment failure
• Antibiotic resistance: Clarithromycin resistance has increased globally from 9% in 1998 to 17.6% in 2008-2009 1
• Probiotics: May show promising results as adjuvant treatment in reducing side effects, though evidence is limited 1

Pitfalls to Avoid

• Avoid PPI-clarithromycin triple therapy without susceptibility testing in regions where clarithromycin resistance exceeds 15-20% 1
• Don't use inadequate PPI dosing: High-dose (twice daily) PPI significantly improves eradication rates 1, 2
• Don't use short treatment durations: 10-14 day regimens are superior to 7-day regimens 1
• Don't fail to verify eradication: Confirmation is essential using non-invasive testing 1

By following these evidence-based recommendations, clinicians can optimize H. pylori eradication rates while minimizing the risk of treatment failure and antibiotic resistance.