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

Recommended Treatment for Helicobacter pylori Infection

In areas with high clarithromycin resistance (≥15%), bismuth-containing quadruple therapy for 14 days is the recommended first-line treatment for H. pylori eradication, while in areas with low clarithromycin resistance (<15%), either 14-day clarithromycin-containing triple therapy or bismuth quadruple therapy can be used. 1, 2, 3

First-Line Treatment Options

Based on Local Clarithromycin Resistance:

• High Resistance Areas (≥15%):

  • Bismuth quadruple therapy: PPI (twice daily) + bismuth subsalicylate/subcitrate (four times daily) + metronidazole (500mg three-four times daily) + tetracycline (500mg four times daily) for 14 days 1, 2
  • Alternative: Concomitant non-bismuth quadruple therapy (PPI + amoxicillin + metronidazole + clarithromycin) for 14 days if bismuth is unavailable 1, 2, 3

• Low Resistance Areas (<15%):

  • Triple therapy: PPI (twice daily) + clarithromycin (500mg twice daily) + amoxicillin (1g twice daily) for 14 days 1, 2
  • Alternative: Bismuth quadruple therapy as described above 1

Optimizing Treatment Efficacy

• Use high-dose PPI (twice daily) to increase treatment efficacy by 8-12% 1, 2
• Extend treatment duration to 14 days rather than 7 days to improve eradication rates by approximately 5% 1, 2
• Consider adding probiotics to reduce antibiotic side effects, though evidence for improved eradication is limited (Grade D recommendation) 1, 2, 3
• PPI-clarithromycin-metronidazole and PPI-clarithromycin-amoxicillin regimens are equivalent in efficacy (Grade A recommendation) 1

Second-Line Treatment Options

• After failure of clarithromycin-containing therapy:
  • Bismuth-containing quadruple therapy (if not used previously) 1, 2
  • Levofloxacin-containing triple therapy: PPI (twice daily) + amoxicillin (1g twice daily) + levofloxacin (500mg once daily or 250mg twice daily) for 14 days 1, 2, 3
• Note: Rising rates of levofloxacin resistance should be considered when selecting this option 1

Third-Line and Rescue Therapy

• After multiple treatment failures:
  • Antimicrobial susceptibility testing should guide therapy whenever possible (Grade A recommendation) 1, 3
  • Consider rifabutin-containing regimens only after failure of at least three prior options 4, 5
  • Use antibiotics not previously used or for which resistance is unlikely 3

Special Considerations

• For penicillin-allergic patients: Replace amoxicillin with tetracycline 1, 2
• For children: Avoid fluoroquinolones and tetracyclines 1, 2
• For verification of eradication: Perform urea breath test or stool antigen test 8 weeks after treatment completion 1, 2
• Do not use serology to confirm eradication 1, 2

Treatment Efficacy Rates

• Recent studies show eradication rates of:
  • Bismuth quadruple therapy (OAMB): 91.3% 6
  • Levofloxacin triple therapy (OAL): 97.3% 6
  • Clarithromycin triple therapy (OAC): 82.2% 6

Common Pitfalls to Avoid

• Do not use clarithromycin-containing regimens without prior susceptibility testing in areas with >15-20% resistance 1
• Do not use short-duration therapy (7 days) as 14-day regimens have superior outcomes 1, 4
• Do not continue using the same antibiotics after treatment failure 1
• Do not underestimate the importance of patient compliance for successful eradication 5

The treatment landscape for H. pylori has evolved significantly due to increasing antibiotic resistance, making it essential to consider local resistance patterns and previous antibiotic exposure when selecting an appropriate regimen 3, 4, 7.