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

Recommended Treatment for Helicobacter pylori Infection

The recommended first-line treatment for H. pylori infection is a 14-day bismuth-containing quadruple therapy in areas with high clarithromycin resistance (>15-20%), 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. 1, 2, 3

First-Line Treatment Options

Treatment selection should be based on local antibiotic resistance patterns, particularly clarithromycin resistance:

• In areas with high clarithromycin resistance (>15-20%):

  • Bismuth-containing quadruple therapy for 14 days 1, 2
  • Concomitant non-bismuth quadruple therapy (PPI + amoxicillin + metronidazole + clarithromycin) for 14 days 4

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

  • Triple therapy with PPI, clarithromycin, and amoxicillin/metronidazole for 14 days 1, 4
  • Bismuth-containing quadruple therapy for 14 days 2

Specific Dosing Recommendations

• Bismuth-containing quadruple therapy:

  • PPI (e.g., esomeprazole 20mg or rabeprazole 20mg) twice daily 3
  • Bismuth subsalicylate/subcitrate (120-140mg) 3-4 times daily 3
  • Metronidazole 500mg 3-4 times daily 3
  • Tetracycline 500mg 4 times daily 3

• Triple therapy with clarithromycin (if used):

  • PPI twice daily 1
  • Amoxicillin 1g twice daily 5
  • Clarithromycin 500mg twice daily 5

Optimizing Treatment Success

• Use high-dose PPI (twice daily) to increase efficacy by approximately 6-10% 1, 2
• Extend treatment duration to 14 days to improve eradication rates by approximately 5% 1, 2
• Consider adding probiotics to reduce side effects, though evidence for improved eradication is limited (Grade D recommendation) 1, 2
• Take medications at the start of meals to minimize gastrointestinal intolerance 5

Second-Line Treatment Options

After failure of first-line therapy:

• If bismuth-containing quadruple therapy was not previously used, it should be the second-line treatment 1, 2
• Levofloxacin-containing triple therapy is an alternative second-line option:
  • PPI twice daily
  • Amoxicillin 1g twice daily
  • Levofloxacin 500mg once daily or 250mg twice daily, for 14 days 1, 2

Special Considerations

• For penicillin-allergic patients:

  • In areas of low clarithromycin resistance: PPI + clarithromycin + metronidazole 1
  • In areas of high clarithromycin resistance: bismuth-containing quadruple therapy 1, 6

• After two treatment failures:

  • Perform antimicrobial susceptibility testing whenever possible 1
  • Use antibiotics not previously used or for which resistance is unlikely 4

• In children:

  • Fluoroquinolones and tetracyclines should not be used, limiting treatment options 2

Verification of Eradication

• Perform urea breath test or monoclonal stool antigen test at least 4 weeks after completing treatment 1
• Serology is not recommended for confirming eradication 1, 2

Common Pitfalls to Avoid

• Using clarithromycin-based regimens in areas with high resistance (>15-20%) leads to treatment failure 1, 7
• Inadequate treatment duration (less than 14 days) reduces eradication success 8
• Using doxycycline instead of tetracycline in bismuth quadruple therapy results in inferior outcomes 3
• Using pantoprazole as the PPI component may reduce efficacy compared to esomeprazole or rabeprazole 3
• Testing for eradication too early (less than 4 weeks after treatment) may lead to false results 1