Recommended Treatment and Dosage for Helicobacter pylori Infection
The first-line treatment for H. pylori infection should be a 14-day bismuth-containing quadruple therapy, especially in areas with high clarithromycin resistance (≥15%). 1, 2
First-Line Treatment Options
In Areas with High Clarithromycin Resistance (≥15%):
- Bismuth quadruple therapy for 14 days: 1, 2
- PPI (proton pump inhibitor) twice daily
- Bismuth subsalicylate/subcitrate four times daily
- Metronidazole 500 mg three or four times daily
- Tetracycline 500 mg four times daily
In Areas with Low Clarithromycin Resistance (<15%):
Triple therapy for 14 days: 1, 2
- PPI twice daily
- Clarithromycin 500 mg twice daily
- Amoxicillin 1 g twice daily
Alternative: Sequential therapy (10-14 days): 1
- First 5 days: PPI + amoxicillin
- Next 5-9 days: PPI + clarithromycin + metronidazole
Optimizing Treatment Efficacy
- Use high-dose PPI (twice daily) to increase treatment efficacy by 6-10% 1, 2
- Preferred PPIs: 40 mg esomeprazole or rabeprazole twice daily (more potent than omeprazole) 1
- Extend treatment duration to 14 days to improve eradication rates by approximately 5% 1, 2
- Consider probiotics as adjuvant treatment to reduce side effects 1, 2
Second-Line Treatment Options
After failure of first-line therapy, choose a regimen that avoids previously used antibiotics: 2, 3
If clarithromycin-based therapy failed:
If bismuth quadruple therapy failed:
Third-Line Treatment
- After two treatment failures, antimicrobial susceptibility testing should guide therapy whenever possible 1, 2
- If testing is unavailable, use antibiotics not previously used 4
Special Considerations
For Patients with Penicillin Allergy:
- In areas of low clarithromycin resistance: 1
- PPI + clarithromycin + metronidazole
- In areas of high clarithromycin resistance: 1
- Bismuth-containing quadruple therapy
FDA-Approved Regimens (per Amoxicillin Label):
- Triple therapy: 5
- Amoxicillin 1 g twice daily
- Clarithromycin 500 mg twice daily
- Lansoprazole 30 mg twice daily
- Duration: 14 days
- Dual therapy: 5
- Amoxicillin 1 g three times daily
- Lansoprazole 30 mg three times daily
- Duration: 14 days
Confirmation of Eradication
- Perform urea breath test or monoclonal stool antigen test at least 4 weeks after completing treatment 1, 2
- Serology should not be used to confirm eradication 1, 2
Common Pitfalls to Avoid
- Using clarithromycin-based therapy in areas with >15% resistance rates leads to treatment failure 1, 3
- Using standard-dose PPI instead of high-dose reduces efficacy 1
- Treating for less than 14 days decreases eradication rates 1, 2
- Failing to test for eradication after treatment 1, 2
- Using previously failed antibiotics in rescue regimens 1, 3