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

Recommended 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 (≥15%), consisting of a proton pump inhibitor (PPI) twice daily, bismuth subsalicylate four times daily, metronidazole 500mg three to four times daily, and tetracycline 500mg four times daily for 14 days. 1, 2

First-Line Treatment Options

The choice of first-line regimen should be based on local patterns of antibiotic resistance:

In areas with high clarithromycin resistance (≥15%):

• Bismuth quadruple therapy for 14 days 3, 1, 2
• Concomitant (non-bismuth quadruple) therapy for 14 days 4

In areas with low clarithromycin resistance (<15%):

• Standard triple therapy: PPI + clarithromycin + amoxicillin (or metronidazole) for 14 days 3, 2
• Bismuth quadruple therapy remains an effective alternative 3, 2

Triple therapy components (if used in low resistance areas):

• PPI twice daily 3
• Clarithromycin 500mg twice daily 3
• Amoxicillin 1g twice daily OR metronidazole 500mg three times daily 3, 5

Optimizing Treatment Success

• Use high-dose PPI (twice daily) to increase efficacy by 8-12% 3, 1
• Extend treatment duration to 14 days rather than 7 days to improve eradication rates by approximately 5% 3, 1
• Take medications at the start of meals to minimize gastrointestinal intolerance 5
• Consider probiotics as adjuvant therapy to reduce side effects, though evidence for increased efficacy is limited 3, 1

Second-Line Treatment Options

After failure of first-line therapy:

• If clarithromycin-based triple therapy was used initially: Use bismuth quadruple therapy 3
• If bismuth quadruple therapy was used initially: Use levofloxacin-based triple therapy 3, 1

Levofloxacin-based triple therapy components:

• PPI twice daily
• Amoxicillin 1g twice daily
• Levofloxacin 500mg once daily or 250mg twice daily for 14 days 1, 2

Third-Line and Rescue Therapies

• After two treatment failures, antimicrobial susceptibility testing should guide therapy whenever possible 3, 1
• Alternative rescue therapies include rifabutin-based triple therapy 2
• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin 2

Special Considerations

For penicillin-allergic patients:

• Amoxicillin can be replaced with tetracycline in treatment regimens 1

For pediatric patients:

• Fluoroquinolones and tetracyclines should not be used in children, limiting treatment options 3, 1
• In children, either PPI-amoxicillin-imidazole or PPI-amoxicillin-clarithromycin or bismuth salts-amoxicillin-imidazole is recommended 3

Verification of Eradication

• Confirm eradication 8 weeks after treatment using either urea breath test or a validated monoclonal stool antigen test 1, 2
• Serology should not be used to confirm eradication 3, 1

Common Pitfalls to Avoid

• Using clarithromycin-containing regimens in areas with >15-20% resistance rates 3, 4
• Inadequate dosing or duration of therapy 3, 6
• Not considering previous antibiotic exposure when selecting regimens 2
• Failing to confirm eradication after treatment 2
• Using serology to confirm eradication 3, 1