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

Treatment of Helicobacter pylori Infection

Bismuth quadruple therapy for 14 days is the preferred first-line treatment for H. pylori infection when antibiotic susceptibility is unknown. 1, 2

First-Line Treatment Options

Preferred Regimen:

• Bismuth Quadruple Therapy (14 days):
  • PPI (proton pump inhibitor) twice daily
  • Bismuth subsalicylate/subcitrate
  • Tetracycline
  • Metronidazole 1

Alternative Regimens:

• In areas with low clarithromycin resistance:

  • Standard Triple Therapy (14 days):
    • PPI twice daily
    • Clarithromycin 500 mg twice daily
    • Amoxicillin 1000 mg twice daily 1, 3

• For patients without penicillin allergy:

  • Rifabutin triple therapy for 14 days
  • Potassium-competitive acid blocker dual therapy for 14 days 2

Treatment for Previously Treated Patients

• For treatment-experienced patients who have not received optimized bismuth quadruple therapy previously:
  • "Optimized" bismuth quadruple therapy for 14 days 2
• For patients previously treated with optimized bismuth quadruple therapy:
  • Rifabutin triple therapy for 14 days 2
• Clarithromycin or levofloxacin-containing regimens should only be used if antibiotic susceptibility is confirmed 2

Important Treatment Considerations

1. Treatment duration: 14 days is recommended for all regimens to achieve higher eradication rates 1
2. Higher doses of PPI improve eradication rates 1
3. Antibiotic resistance is the most important factor affecting treatment success 4
4. Local resistance patterns should guide antibiotic selection 4
5. Medication timing: Take medications at the start of a meal to minimize gastrointestinal intolerance 3

Post-Treatment Testing

• Universal post-treatment testing is essential to confirm eradication 1, 2
• Use urea breath test (UBT) or stool antigen test at least 4 weeks after completion of therapy 1
• Avoid testing within 4 weeks of PPI use or 2 weeks of antibiotic use to prevent false negatives 1

Special Populations Requiring H. pylori Eradication

• First-degree relatives of patients with gastric cancer
• Patients with previous gastric neoplasia
• Patients with severe gastritis (severe pan-gastritis, corpus-predominant gastritis, severe atrophy)
• Patients on long-term acid inhibition (>1 year)
• Patients with strong environmental risk factors for gastric cancer
• Patients with extraintestinal manifestations (iron deficiency anemia, ITP, vitamin B12 deficiency) 4, 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: Shorter courses have lower eradication rates
2. Mono-antibiotic therapy: Increases risk of antibiotic resistance 4
3. Poor patient compliance: Ensure patients understand the importance of completing the full course
4. Ignoring local resistance patterns: Treatment should be tailored to local H. pylori antibiotic resistance patterns 4
5. Failure to confirm eradication: Essential in high-risk patients (complicated peptic ulcer disease, gastric ulcer, MALT lymphoma) 4

H. pylori infection is a serious global infectious disease with significant morbidity and mortality risks. Proper eradication not only treats the current infection but also reduces the risk of serious complications including peptic ulcer disease and gastric cancer 5.