What is the recommended treatment for H Pylori (Helicobacter Pylori) gastritis in the West Bengal region of India?

Treatment of H. Pylori Gastritis in West Bengal, India

In West Bengal, India, bismuth-containing quadruple therapy is the recommended first-line treatment for H. pylori gastritis due to high clarithromycin resistance rates in the region. 1, 2

First-Line Treatment Options

Recommended First-Line: Bismuth Quadruple Therapy (14 days)

• Bismuth subsalicylate (4 times daily) 1
• Tetracycline 500 mg (4 times daily) 1, 2
• Metronidazole 500 mg (3-4 times daily) 1, 2
• Proton pump inhibitor (PPI) in high dose (twice daily) 1

This regimen is particularly appropriate for regions with high clarithromycin resistance (>15-20%), which is likely the case in West Bengal, India 1.

Alternative if Bismuth is Unavailable

• Non-bismuth quadruple therapy (concomitant therapy) or sequential therapy can be considered if bismuth is not available 1, 2
• Sequential therapy consists of 5 days PPI + amoxicillin, followed by 5 days PPI + clarithromycin + metronidazole 1

Optimization Strategies

Improving Efficacy

• Use high-dose PPI (twice daily) to increase treatment efficacy 1, 2
• Extend treatment duration to 14 days rather than 7-10 days to improve eradication rates by approximately 5% 1, 2
• Consider adding probiotics to reduce side effects, particularly diarrhea, which affects 21-41% of patients during treatment 3

Considerations for West Bengal Region

• Local antibiotic resistance patterns should guide therapy selection 1, 2
• The WHO Access, Watch, and Reserve (AWaRe) classification recommends using antibiotics with lower resistance potential (amoxicillin, tetracycline, metronidazole) over those with higher resistance potential (clarithromycin, levofloxacin) 1
• Bismuth quadruple therapy is particularly suitable for mass eradication programs in regions with high gastric cancer risk 1

Second-Line Treatment Options

After Failure of First-Line Therapy

• If bismuth quadruple therapy fails, consider levofloxacin-containing triple therapy 1
• Levofloxacin triple therapy consists of: PPI (twice daily) + amoxicillin 1g (twice daily) + levofloxacin 500mg (once daily) or 250mg (twice daily) for 14 days 1, 2
• Rising rates of levofloxacin resistance should be considered before prescribing 1

Third-Line Options

• After failure of second-line therapy, treatment should be guided by antimicrobial susceptibility testing whenever possible 1
• Rifabutin-based triple therapy may be considered as a rescue treatment 1

Special Considerations

Penicillin Allergy

• For patients with penicillin allergy, use PPI + clarithromycin + metronidazole in areas of low clarithromycin resistance 1
• In areas of high clarithromycin resistance (like West Bengal), bismuth quadruple therapy is preferred even for penicillin-allergic patients 1

Verification of Eradication

• Confirm eradication with urea breath test or monoclonal stool antigen test at least 4 weeks after completing therapy 1, 2
• Serology is not appropriate for confirming eradication 1, 2

Common Pitfalls to Avoid

• Do not use clarithromycin-containing triple therapy without susceptibility testing in regions where clarithromycin resistance exceeds 15-20% 1
• Do not use short-duration therapy (7 days); 14-day regimens are more effective 1, 4
• Do not fail to verify eradication after treatment 1
• Do not use levofloxacin in patients with chronic bronchopneumopathy who may have previously received fluoroquinolones 1