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

H. Pylori Treatment Recommendations

Bismuth quadruple therapy is recommended as first-line treatment for H. pylori infection, especially in areas with high clarithromycin resistance (>15-20%), consisting of a proton pump inhibitor (PPI) twice daily, bismuth subsalicylate, metronidazole, and tetracycline for 14 days. 1, 2, 3

First-line Treatment Options

• In areas with high clarithromycin resistance (>15-20%), bismuth quadruple therapy is strongly recommended as first-line treatment 3, 1
• In areas with low clarithromycin resistance (<10%), clarithromycin-containing triple therapy may still be used, consisting of PPI + clarithromycin + amoxicillin (or metronidazole) for 10-14 days 3, 1
• Triple therapy (PPI + clarithromycin + amoxicillin) has decreased in efficacy over time, often achieving only 70% eradication rates, which is below the target of 80% 3
• The FDA-approved dosage for H. pylori triple therapy is 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 4

Optimizing Treatment Efficacy

• High-dose PPI (twice daily) significantly increases the efficacy of triple therapy by 6-10% compared to standard doses 3
• Extending treatment duration from 7 to 10-14 days improves eradication success by approximately 5% 3, 1
• PPI-clarithromycin-metronidazole (PCM) and PPI-clarithromycin-amoxicillin (PCA) regimens are equivalent in efficacy 3
• Bismuth is particularly valuable because bacterial resistance to this compound is extremely rare 2, 1

Sequential and Non-Bismuth Quadruple Therapy

• Sequential therapy consists of 5 days of PPI + amoxicillin, followed by 5 days of PPI + clarithromycin + metronidazole 3
• Non-bismuth quadruple therapy (concomitant therapy) involves simultaneous administration of PPI + amoxicillin + clarithromycin + metronidazole 3
• These regimens are alternatives when bismuth-containing quadruple therapy is not available in high clarithromycin resistance areas 3

Second-line Treatment Options

• After failure of clarithromycin-based triple therapy, bismuth quadruple therapy is recommended 3, 1
• Levofloxacin-based triple therapy (PPI + amoxicillin + levofloxacin) is an alternative second-line option 3, 1
• Rising rates of levofloxacin resistance should be taken into account when selecting this regimen 3

Third-line and Rescue Therapies

• After failure of second-line treatment, therapy should be guided by antimicrobial susceptibility testing whenever possible 3, 1
• Alternative rescue therapies include rifabutin-based triple therapy for patients who have failed multiple treatment attempts 1

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 1
• Confirm eradication after treatment using either urea breath test or a validated monoclonal stool test (not serology) 3
• Probiotics may help reduce side effects of treatment, though evidence for this is limited 3
• Medications should be taken with meals to minimize gastrointestinal intolerance 4
• For dual therapy (when clarithromycin cannot be used), the FDA-approved dosage is 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days 4

Special Populations

• Patients with renal impairment (GFR <30 mL/min) should not receive the 875 mg dose of amoxicillin 4
• For patients with penicillin allergy, treatment regimens need to be modified accordingly, with bismuth quadruple therapy being a suitable option 1