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

Recommended Treatment for H. 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

When antibiotic susceptibility is unknown:

1. Bismuth quadruple therapy (14 days) 1, 2

   • Preferred regimen due to increasing clarithromycin resistance worldwide
   • Eradication rate: approximately 85%

2. Concomitant non-bismuth quadruple therapy (14 days) 1, 3

   • Alternative first-line option
   • Eradication rate: approximately 80%
   • Particularly useful in areas with high clarithromycin resistance (≥15%)

3. Triple therapy (14 days) 1, 4

   • Consists of:
     • 1 gram amoxicillin twice daily
     • 500 mg clarithromycin twice daily
     • 30 mg lansoprazole twice daily
   • Only recommended in areas with low clarithromycin resistance (<15%)
   • Eradication rate: approximately 85% when resistance is low

Second-Line Treatment Options

If first-line therapy fails, second-line treatment should avoid antibiotics previously used 1:

1. Levofloxacin-based triple therapy (14 days) 3, 5

   • Option when bismuth quadruple therapy was used first-line

2. Bismuth quadruple therapy (14 days) 3

   • If not previously used as first-line treatment

Treatment After Multiple Failures

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

1. Rifabutin-based triple therapy
2. High-dose dual therapy
3. Antimicrobial susceptibility testing (AST) should be performed to guide therapy

Special Considerations

Penicillin Allergy

• Patients with true penicillin allergy can be treated with bismuth quadruple therapy using tetracycline instead of amoxicillin 1
• Alternative regimens using levofloxacin or other bismuth-based therapies may be considered

Antibiotic Resistance

• Increasing resistance to clarithromycin, levofloxacin, and metronidazole is a major cause of treatment failure 1, 6
• Local antibiotic resistance patterns should guide therapy selection when available

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 non-invasive test (sensitivity 95%, specificity 90%)
  • Monoclonal stool antigen test - equivalent accuracy to UBT

Important Clinical Pearls

• Antibiotic stewardship: To reduce the development of drug-resistant bacteria, amoxicillin should be used only to treat infections that are proven or strongly suspected to be caused by bacteria 4
• Medication timing: To minimize gastrointestinal intolerance, amoxicillin should be taken at the start of a meal 4
• Dietary management: A diet low in acidic, spicy, and fatty foods, along with regular consumption of fruits and vegetables rich in vitamin C, is recommended for patients with epigastric pain and a history of H. pylori infection 1
• Surveillance: Patients with risk factors for gastric cancer or atrophic gastritis should undergo surveillance endoscopy every 3 years 1
• Alarm symptoms: Patients aged ≥55 or with alarm symptoms should be referred for prompt endoscopy with H. pylori testing 1

Common Pitfalls to Avoid

1. Using clarithromycin-based regimens in areas with high resistance - This leads to treatment failure and further resistance development
2. Inadequate treatment duration - 14-day regimens are superior to shorter courses
3. Not confirming eradication - All patients should undergo testing to confirm successful eradication
4. Testing too soon after treatment - Wait at least 4 weeks after antibiotics to avoid false negative results
5. Reusing previously failed antibiotics - Second-line therapy should avoid antibiotics used in failed first-line regimens