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

Treatment for Helicobacter pylori Infection

Bismuth quadruple therapy is the recommended first-line treatment for H. pylori infection, especially in areas with high clarithromycin resistance, and should include a proton pump inhibitor (PPI) twice daily, subsalicilato de bismuto, metronidazole, and tetracycline for 10-14 days. 1

First-line Treatment Options

The selection of appropriate first-line therapy depends on local clarithromycin resistance patterns:

In Areas with Low Clarithromycin Resistance (<15-20%):

• Standard triple therapy may still be used: PPI + clarithromycin + amoxicillin (or metronidazole) for 10-14 days 2
• Bismuth-containing quadruple therapy is also an effective alternative in these regions 2

In Areas with High Clarithromycin Resistance (>15-20%):

• Bismuth-containing quadruple therapy is strongly recommended as first-line treatment 2, 1
• If bismuth is unavailable, non-bismuth quadruple therapy options include:
  • Sequential therapy: 5 days of PPI + amoxicillin followed by 5 days of PPI + clarithromycin + metronidazole 2
  • Concomitant therapy: PPI + amoxicillin + clarithromycin + metronidazole taken simultaneously 2

Optimizing Treatment Efficacy

• Use high-dose PPI (twice daily) to increase treatment efficacy 2
• Extend treatment duration to 14 days rather than 7 days to improve eradication rates by approximately 5% 2
• Consider adding probiotics as adjuvant therapy to reduce side effects, though evidence for this is limited 2
• Ensure patient compliance, as poor compliance significantly reduces eradication rates 2

Second-line Treatment Options

After failure of first-line therapy, treatment options include:

• If clarithromycin-based triple therapy failed initially, use bismuth quadruple therapy 2
• Levofloxacin-based triple therapy (PPI + amoxicillin + levofloxacin) is an alternative second-line option 2
• Consider rising rates of levofloxacin resistance when selecting this option 2

Third-line and Rescue Therapies

• After two treatment failures, antimicrobial susceptibility testing should guide therapy whenever possible 2
• Alternative rescue therapies include:
  • Rifabutin-based triple therapy 2, 1
  • High-dose dual amoxicillin-PPI therapy 2, 1
  • Furazolidone-containing regimens 3

Important Considerations and Pitfalls

• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin, as resistance is likely to have developed 2, 1
• Bismuth is valuable because bacterial resistance to this compound is extremely rare 1
• Confirm eradication after treatment using either urea breath test or a validated monoclonal stool test (not serology) 2
• The increasing prevalence of antibiotic resistance is the key factor for treatment failure 4
• Amoxicillin is FDA-approved for H. pylori treatment in combination with clarithromycin plus lansoprazole (triple therapy) or with lansoprazole alone (dual therapy) 5

Specific Regimen Recommendations

Bismuth Quadruple Therapy:

• PPI (standard dose) twice daily
• Bismuth subsalicylate 524 mg four times daily
• Metronidazole 250-500 mg four times daily
• Tetracycline 500 mg four times daily
• Duration: 10-14 days (14 days preferred for maximum efficacy) 1

This regimen achieves eradication rates >80% even in areas with high antibiotic resistance 1, 2.