Bismuth Quadruple Therapy for H. pylori Infection
The recommended treatment for H. pylori infection is bismuth quadruple therapy for 14 days, which has an eradication rate of approximately 85% and is the preferred first-line treatment when antibiotic susceptibility is unknown. 1
Standard Bismuth Quadruple Therapy Regimen
The standard bismuth quadruple therapy consists of:
- Proton pump inhibitor (PPI) - standard dose twice daily
- Bismuth subsalicylate - 525 mg four times daily
- Tetracycline - 500 mg four times daily
- Metronidazole - 500 mg three to four times daily
- Duration: 14 days
This regimen is particularly valuable because it avoids the issue of clarithromycin resistance, which is increasingly common worldwide 2.
Alternative Bismuth-Based Regimens
If the standard bismuth quadruple therapy is not available, the following alternatives can be considered:
Bismuth + PPI + Amoxicillin + Clarithromycin: This regimen has shown good safety outcomes 3, but should only be used in areas with low clarithromycin resistance.
Bismuth + PPI + Furazolidone + Tetracycline: This combination has demonstrated excellent eradication rates (SUCRA 97.5) in network meta-analyses 3.
Important Considerations
Antibiotic Resistance
- Local antibiotic resistance patterns should guide therapy selection when available 1
- Previously used antibiotics should be avoided in subsequent eradication attempts if first-line therapy fails 1, 4
Safety Considerations
- Caution should be exercised when combining bismuth with PPIs, as acid suppression may increase bismuth absorption 5
- Blood bismuth levels can reach the "alarm level" (50-100 μg/L) in approximately 8.8% of patients receiving bismuth with PPIs 5
Treatment Duration
- 14-day treatment duration is strongly associated with better eradication rates compared to shorter regimens 6
- The eradication rate increases to 93% (intention-to-treat) with 14-day bismuth quadruple therapy 6
Second-Line Options
If bismuth quadruple therapy fails:
- Levofloxacin-based triple therapy for 10-14 days is recommended 1
- Avoid antibiotics previously used in the failed regimen 1, 4
Special Populations
For patients with penicillin allergy:
- Bismuth quadruple therapy with tetracycline is an excellent option as it does not contain amoxicillin 1
Confirmation of Eradication
- Wait at least 4 weeks after completing antibiotic therapy before testing for H. pylori eradication 1
- Use either urea breath test or stool antigen test (both have >90% sensitivity and specificity) 1
Bismuth quadruple therapy has emerged as the preferred first-line treatment for H. pylori infection due to increasing antibiotic resistance worldwide, particularly to clarithromycin. The 14-day regimen provides the highest eradication rates and should be the standard approach when antibiotic susceptibility testing is not available.