Recommended Doses for Quadruple Therapy in H. pylori Treatment
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
Bismuth Quadruple Therapy (Preferred First-Line)
The standard bismuth quadruple therapy consists of:
- PPI (standard dose twice daily)
- Bismuth subcitrate (220 mg twice daily)
- Tetracycline (500 mg four times daily)
- Metronidazole (500 mg three times daily)
- Duration: 14 days 1, 2
Alternative Quadruple Therapy Options
Concomitant Non-Bismuth Quadruple Therapy
- PPI (standard dose twice daily)
- Amoxicillin (1 gram twice daily)
- Metronidazole (500 mg twice daily)
- Clarithromycin (500 mg twice daily)
- Duration: 14 days 1
Modified Bismuth Quadruple Therapy
- PPI (standard dose twice daily)
- Bismuth subcitrate (220 mg twice daily)
- Amoxicillin (1 gram twice daily)
- Clarithromycin (500 mg twice daily) OR Tetracycline (500 mg four times daily)
- Duration: 14 days 2
Important Considerations
Duration of Therapy
- Recent evidence strongly supports 14-day regimens over shorter durations for all H. pylori eradication therapies 1
- Although a 2024 study showed non-inferior efficacy of 10-day bismuth quadruple therapy compared to 14-day regimens (93.22% vs. 93.74% eradication rates), the current guidelines still recommend 14 days 2
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
- Bismuth quadruple therapy is preferred in areas with high clarithromycin resistance
Special Populations
- For patients with penicillin allergy, bismuth quadruple therapy with tetracycline instead of amoxicillin is recommended 1
- For patients who have failed previous treatment, avoid previously used antibiotics 1
Administration Timing
- Some evidence suggests that taking quadruple therapy at mid-day and evening (rather than morning and evening) may improve efficacy, with one study showing 92.3% eradication rates with this timing 3
Second-Line Options
If first-line bismuth quadruple therapy fails:
- Levofloxacin-based triple therapy for 10-14 days 1
- Rifabutin-based triple therapy (for patients who have failed two previous treatment attempts) 1
- High-dose dual therapy (for patients who have failed two previous treatment attempts) 1
Monitoring and Follow-up
- Wait at least 4 weeks after completing antibiotic therapy before testing for H. pylori eradication 1
- Use urea breath test or stool antigen test to confirm eradication 1
Remember that the increasing resistance of H. pylori to antibiotics necessitates careful selection of appropriate therapy regimens based on local resistance patterns when available.