What is the treatment for Helicobacter pylori (H. 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
  • Components: Proton pump inhibitor (PPI) + Bismuth + Tetracycline + Metronidazole
  • Eradication rate: ~85%
  • Advantage: Effective even in areas with high clarithromycin resistance

Alternative First-Line Regimens:

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

   • Eradication rate: ~80%
   • Use when bismuth is unavailable

2. Standard triple therapy (14 days) 1

   • Components: PPI + Clarithromycin + Amoxicillin
   • Eradication rate: ~85%
   • Only recommended in areas with low clarithromycin resistance
   • FDA approved: Amoxicillin in combination with clarithromycin plus lansoprazole 2

Second-Line Treatment Options

If first-line therapy fails, avoid previously used antibiotics, particularly if treatment failure is suspected due to antibiotic resistance 1:

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

Salvage Therapy 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, 3

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

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

Dual Therapy Option

• Amoxicillin with lansoprazole as dual therapy is indicated for patients allergic or intolerant to clarithromycin or when clarithromycin resistance is suspected 2

Antibiotic Resistance Concerns

• Increasing resistance to clarithromycin, levofloxacin, and metronidazole is a major cause of treatment failure 1, 3, 4
• Local antibiotic resistance patterns should guide therapy selection when available 1
• Consider susceptibility testing, especially after treatment failure 3, 4

Confirmation of Eradication

• Wait at least 4 weeks after completing antibiotic therapy before testing for H. pylori eradication 1
• Preferred tests:
  • Urea Breath Test (UBT) - gold standard with 95% sensitivity and 90% specificity 1
  • Monoclonal stool antigen test - equivalent accuracy to UBT 1

Common Pitfalls to Avoid

1. Using clarithromycin-based therapy in areas with high resistance

   • This can lead to treatment failure; bismuth quadruple therapy is preferred in these regions 1, 3

2. Insufficient treatment duration

   • 14-day regimens are generally more effective than 7-day or 10-day regimens 1, 5

3. Reusing previously failed antibiotics

   • Avoid antibiotics used in failed treatments, particularly clarithromycin 1, 4

4. Inadequate acid suppression

   • Proper PPI dosing is essential for antibiotic efficacy 3

5. Testing for eradication too soon

   • Wait at least 4 weeks after therapy completion for accurate results 1

Dietary and Lifestyle Recommendations

• Diet low in acidic, spicy, and fatty foods 1
• Regular consumption of fruits and vegetables rich in vitamin C 1
• Smaller, more frequent meals 1
• Avoid eating within 3 hours of bedtime 1
• Stay hydrated with water throughout the day 1

The treatment landscape for H. pylori continues to evolve in response to increasing antibiotic resistance. While newer options like levofloxacin-based regimens show promise 5, bismuth quadruple therapy remains the most reliable first-line option when antibiotic susceptibility is unknown 1, 3.