What is the recommended treatment for H pylori infection?

Recommended Treatment for Helicobacter pylori Infection

Bismuth quadruple therapy for 14 days is the preferred first-line treatment for H. pylori infection, especially in areas with high clarithromycin resistance (>15-20%). 1, 2, 3

First-Line Treatment Options

• In areas with high clarithromycin resistance (>15-20%), bismuth-containing quadruple therapy is strongly recommended as first-line treatment, consisting of:

  • PPI (twice daily, high dose)
  • Bismuth subsalicylate/subcitrate (four times daily)
  • Metronidazole (500 mg three or four times daily)
  • Tetracycline (500 mg four times daily)
  • Duration: 14 days 4, 1, 2

• In areas with low clarithromycin resistance (<15%), clarithromycin-containing triple therapy may still be used:

  • PPI (twice daily, high dose)
  • Clarithromycin (500 mg twice daily)
  • Amoxicillin (1000 mg twice daily) or metronidazole
  • Duration: 14 days 4, 2

• Concomitant non-bismuth quadruple therapy is an alternative when bismuth is unavailable:

  • PPI + amoxicillin + metronidazole + clarithromycin
  • Duration: 14 days 1, 5

Optimizing Treatment Efficacy

• Use high-dose PPI (twice daily) to increase treatment efficacy by 8-12% 4, 1, 2
• Extend treatment duration to 14 days rather than 7 days to improve eradication rates by approximately 5% 4, 1, 2
• Consider adding probiotics as adjuvant therapy to reduce side effects, though evidence for this is limited 4, 1, 2
• PPI-clarithromycin-metronidazole and PPI-clarithromycin-amoxicillin regimens are equivalent in efficacy 4

Second-Line Treatment Options

• After failure of clarithromycin-containing therapy, use:

  • Bismuth quadruple therapy (if not used initially) OR
  • Levofloxacin-containing triple therapy:
    • PPI (twice daily)
    • Amoxicillin (1000 mg twice daily)
    • Levofloxacin (500 mg once daily or 250 mg twice daily)
    • Duration: 14 days 4, 1, 2

• Rising rates of levofloxacin resistance should be taken into account when selecting this regimen 4, 2

Third-Line and Rescue Therapies

• After failure of second-line treatment, antimicrobial susceptibility testing should guide therapy whenever possible 4, 1, 2
• Rifabutin-based triple therapy should be restricted to patients who have failed at least 3 prior treatment options 1, 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, 3
• For patients allergic to penicillin, amoxicillin can be replaced with tetracycline 1
• Confirm eradication after treatment using either urea breath test or a validated monoclonal stool test (not serology) at least 8 weeks after completing therapy 4, 1, 2
• In patients with high BMI, especially obese people, treatment failure may be more likely due to higher distribution volume of drugs 4
• Smoking is a risk factor for treatment failure (OR 1.95) 4

Specific FDA-Approved Regimen for H. pylori

• Triple therapy (for adults):

  • 1 gram amoxicillin
  • 500 mg clarithromycin
  • 30 mg lansoprazole
  • All given twice daily for 14 days 6

• Dual therapy (for adults):

  • 1 gram amoxicillin
  • 30 mg lansoprazole
  • All given three times daily for 14 days 6