What is the recommended triple therapy regimen for the treatment of Helicobacter pylori (H. pylori) infection?

Triple Therapy for H. pylori Infection

The recommended triple therapy regimen for H. pylori infection is 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days. 1

First-Line Treatment Options

When selecting a treatment regimen for H. pylori infection, the following options should be considered:

1. Triple therapy (when clarithromycin resistance is low <15%):

   • Amoxicillin 1g twice daily
   • Clarithromycin 500mg twice daily
   • PPI (e.g., lansoprazole 30mg) twice daily
   • Duration: 14 days
   • Eradication rate: approximately 85% 2

2. Bismuth quadruple therapy (preferred when antibiotic susceptibility is unknown):

   • PPI twice daily
   • Bismuth subsalicylate
   • Tetracycline
   • Metronidazole
   • Duration: 14 days
   • Eradication rate: approximately 85% 2, 3

3. Concomitant non-bismuth quadruple therapy (for areas with high clarithromycin resistance ≥15%):

   • PPI
   • Clarithromycin
   • Amoxicillin
   • Metronidazole
   • Duration: 14 days
   • Eradication rate: approximately 80% 2, 4

Important Considerations

• Antibiotic resistance: Clarithromycin resistance is increasingly common worldwide, making bismuth quadruple therapy often preferred as first-line treatment 2, 3
• Previous antibiotic exposure: Patients should be asked about previous antibiotic exposure before selecting a regimen 5
• Administration: Medications should be taken at the start of a meal to minimize gastrointestinal intolerance 1
• Duration: 14-day regimens are recommended for optimal eradication rates 2, 1, 3

Special Populations

• Penicillin allergy: Patients with true penicillin allergy can be treated with bismuth quadruple therapy using tetracycline instead of amoxicillin 2
• Renal impairment: Patients with severe renal impairment (GFR <30 mL/min) require dose adjustments of amoxicillin 1

Confirmation of Eradication

• Wait at least 4 weeks after completing antibiotic therapy before testing for H. pylori eradication 2
• Preferred tests include:
  • Urea Breath Test (sensitivity 95%, specificity 90%)
  • Monoclonal stool antigen test (equivalent accuracy) 2

Second-Line Treatment

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

• Levofloxacin triple therapy (if bismuth quadruple therapy was used first) 2, 5
• Bismuth quadruple therapy (if not previously used) 2, 5
• Rifabutin-based triple therapy (for patients who have failed two previous treatment attempts) 2, 3

Common Pitfalls to Avoid

1. Using clarithromycin-based regimens in areas of high resistance without susceptibility testing
2. Insufficient treatment duration (less than 14 days)
3. Testing for eradication too soon after completing therapy (should wait at least 4 weeks)
4. Reusing antibiotics that were previously used in failed regimens
5. Inadequate acid suppression during treatment

Triple therapy remains an effective option in areas with low clarithromycin resistance, but bismuth quadruple therapy is increasingly recommended as first-line treatment due to rising antibiotic resistance patterns worldwide.