What is the recommended treatment regimen for H pylori (Helicobacter pylori) infection?

Recommended Treatment Regimens for 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

The choice of first-line therapy should be guided by local clarithromycin resistance patterns:

In areas with high clarithromycin resistance (≥15%):

• Bismuth quadruple therapy (14 days) 1, 2

  • Proton pump inhibitor (PPI) twice daily
  • Bismuth salt twice daily
  • Tetracycline four times daily
  • Metronidazole three times daily

• Concomitant non-bismuth quadruple therapy (14 days) 1, 2

  • PPI twice daily
  • Amoxicillin twice daily
  • Clarithromycin twice daily
  • Metronidazole twice daily

In areas with low clarithromycin resistance (<15%):

• Triple therapy (14 days) 3, 2
  • PPI twice daily
  • Amoxicillin 1 gram twice daily
  • Clarithromycin 500 mg twice daily

FDA-Approved Dosing for H. pylori Eradication

The FDA label specifically recommends: 3

• Triple therapy: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days
• Dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, all given three times daily for 14 days

Second-Line Treatment Options

If first-line therapy fails, second-line options include: 1, 2

• Levofloxacin triple therapy (14 days) if not previously used
• Bismuth quadruple therapy (14 days) if not previously used

Special Populations

Patients with penicillin allergy:

• Bismuth quadruple therapy with tetracycline instead of amoxicillin 1, 4
• Alternative regimens using levofloxacin or bismuth-based therapies 1

Pregnant patients:

• Avoid invasive diagnostic procedures unless absolutely necessary 1
• If needed, perform preferably in the second trimester 1

Breastfeeding patients:

• Most medications used for H. pylori treatment are compatible with breastfeeding 1

Confirmation of Eradication

• Wait at least 4 weeks after completing antibiotic therapy before testing 1
• Preferred tests: 1
  • Urea Breath Test (UBT) - sensitivity 95%, specificity 90%
  • Monoclonal stool antigen test - equivalent accuracy

Treatment Failures

For patients who have failed two previous treatment attempts: 1, 2

• Rifabutin-based triple therapy
• High-dose dual therapy
• Consider antimicrobial susceptibility testing
• Use antibiotics not previously used or for which resistance is unlikely

Common Pitfalls and Caveats

1. Increasing antibiotic resistance: Clarithromycin, levofloxacin, and metronidazole resistance is a major cause of treatment failure. When possible, local antibiotic resistance patterns should guide therapy selection. 1

2. Inadequate acid suppression: High-dose potent PPI is recommended to achieve adequate acid suppression and improve eradication rates. 2

3. Premature testing for eradication: Testing before 4 weeks after therapy completion can lead to false negative results. 1

4. Poor compliance: Compliance is a significant factor affecting H. pylori eradication. The complexity and duration of treatment regimens can affect adherence. 5

5. Dietary factors: Patients should avoid acidic, spicy, and fatty foods during treatment to prevent irritation of the gastric lining. 1

Recent evidence from 2024 suggests that levofloxacin-containing triple therapy (omeprazole, amoxicillin, levofloxacin) achieved a 97.3% eradication rate, which was higher than clarithromycin-based triple therapy (82.2%), though not statistically superior to quadruple therapy with bismuth (91.3%). 6