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

Recommended Treatment for Helicobacter Pylori Infection

Bismuth quadruple therapy is currently recommended as first-line treatment for H. pylori infection, especially in areas with high clarithromycin resistance, and should include a proton pump inhibitor (PPI) twice daily, subsalicilato de bismuto, metronidazole, and tetracycline for 14 days. 1

First-Line Treatment Options

• Bismuth quadruple therapy: PPI twice daily + bismuth subsalicylate 524 mg four times daily + metronidazole + tetracycline for 14 days is recommended by the American Gastroenterological Association to maximize eradication efficacy 1
• Triple therapy: In areas with low clarithromycin resistance, PPI-based triple therapy using a PPI with two antibiotics (clarithromycin and amoxicillin or metronidazole) for 7-14 days may be considered 2
• FDA-approved regimen for H. pylori in adults includes:
  • Triple therapy: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 3
  • Dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days 3

Treatment Duration and Dosing

• The recommended duration for bismuth quadruple therapy is 10-14 days, with 14 days being preferred to maximize eradication rates 1
• For triple therapy regimens, the FDA recommends a 14-day course 3
• Amoxicillin dosing for H. pylori treatment in adults is 1 gram twice daily (triple therapy) or 1 gram three times daily (dual therapy) 3

Considerations for Treatment Selection

• Antibiotic resistance is the key factor for treatment failure, particularly clarithromycin resistance 2, 4
• Bismuth is valuable because bacterial resistance to this compound is extremely rare, making bismuth quadruple therapy effective even against strains resistant to metronidazole 1
• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin, to maximize the probability of successful eradication 1
• The stomach's acidity affects antibiotic efficacy, which is why PPIs are a crucial component of all H. pylori treatment regimens 2

Managing Treatment Side Effects

• Diarrhea occurs in 21-41% of patients during the first week of H. pylori eradication therapy due to disruption of normal gut microbiota 5
• Consider adjunctive probiotics to reduce the risk of diarrhea and improve patient compliance 5
• Other common adverse reactions include rash, vomiting, and nausea 3
• Taking medications at the start of a meal can minimize gastrointestinal intolerance 3

Second-Line and Rescue Therapies

• After failed first-line therapy, an alternative regimen should be selected based on prior antibiotic exposure 1
• If bismuth quadruple therapy fails, rifabutin triple therapy for 14 days is a suitable empiric alternative 4
• After two failed eradication attempts, antibiotic susceptibility testing is recommended to guide further treatment 2, 1
• Alternative options for refractory cases include high-dose dual therapy with amoxicillin and PPI 1

Post-Treatment Evaluation

• Confirmation of H. pylori eradication should be performed at least 4 weeks after completion of therapy 4
• Treatment should continue for at least 48 to 72 hours beyond symptom resolution 3

Special Considerations

• For patients with renal impairment (GFR 10-30 mL/min), amoxicillin dosage should be adjusted to 500 mg or 250 mg every 12 hours 3
• Patients with severe renal impairment (GFR <10 mL/min) should receive 500 mg or 250 mg every 24 hours 3
• Patients on hemodialysis require an additional dose both during and at the end of dialysis 3

By following these evidence-based recommendations, clinicians can optimize H. pylori eradication rates while minimizing adverse effects and antibiotic resistance.