H. pylori Treatment Recommendations
In areas of high clarithromycin resistance (>15%), bismuth-containing quadruple therapy for 14 days is recommended as first-line treatment for H. pylori infection; in areas of low clarithromycin resistance (<15%), either clarithromycin-containing triple therapy or bismuth quadruple therapy is recommended. 1, 2
First-Line Treatment Options
Areas with High Clarithromycin Resistance (>15%)
- Bismuth-containing quadruple therapy for 14 days is the preferred first-line treatment 1
- PPI (twice daily)
- Bismuth subsalicylate/subcitrate (four times daily)
- Metronidazole (500 mg three or four times daily)
- Tetracycline (500 mg four times daily)
- If bismuth is unavailable, non-bismuth quadruple therapy (concomitant or sequential) is recommended 1, 2
Areas with Low Clarithromycin Resistance (<15%)
- Clarithromycin-containing triple therapy for 14 days 1
- PPI (twice daily)
- Clarithromycin (500 mg twice daily)
- Amoxicillin (1 g twice daily) or Metronidazole (500 mg three times daily)
- Bismuth-containing quadruple therapy is also an effective alternative 1
Optimizing Treatment Success
- Use high-dose PPI (twice daily) to increase treatment efficacy 1, 2
- Extend treatment duration to 14 days to improve eradication rates by approximately 5% 1, 2
- PPI-clarithromycin-metronidazole and PPI-clarithromycin-amoxicillin regimens are equally effective when using the same dose of clarithromycin 1
- Take medications at the start of a meal to minimize gastrointestinal intolerance 3
- Consider probiotics as adjunctive therapy to reduce antibiotic side effects, though evidence for improved eradication is limited 1, 2
Second-Line Treatment
- After failure of clarithromycin-containing therapy, either bismuth-containing quadruple therapy (if not previously used) or levofloxacin-containing triple therapy is recommended 1, 2
- Levofloxacin-containing triple therapy consists of 1, 2:
- PPI (twice daily)
- Amoxicillin (1 g twice daily)
- Levofloxacin (500 mg once daily or 250 mg twice daily) for 14 days
- Rising rates of levofloxacin resistance should be considered when selecting this regimen 1, 2
Third-Line Treatment
- After failure of second-line treatment, antimicrobial susceptibility testing is recommended whenever possible 1, 2
- If testing is unavailable, consider using antibiotics not previously used or for which resistance is unlikely 4
- Options include rifabutin-based triple therapy or high-dose dual therapy (PPI and amoxicillin four times daily) 1
Special Considerations
- For patients allergic to penicillin, amoxicillin can be replaced with tetracycline 2
- In children, fluoroquinolones and tetracyclines should not be used, limiting treatment options 1, 2
- For H. pylori eradication in duodenal ulcer disease, FDA-approved regimens include 3:
- Triple therapy: Amoxicillin (1 g), clarithromycin (500 mg), and lansoprazole (30 mg), all twice daily for 14 days
- Dual therapy: Amoxicillin (1 g) and lansoprazole (30 mg), each three times daily for 14 days