What are the types of treatment regimens for H. pylori (Helicobacter pylori) infection?

H. pylori Treatment Regimens

The choice of H. pylori eradication regimen should be based on local clarithromycin resistance patterns, with bismuth-containing quadruple therapy recommended as first-line treatment in areas with high clarithromycin resistance (>15-20%), while clarithromycin-containing triple therapy remains appropriate in areas with low resistance rates. 1, 2

First-Line Treatment Options

Areas with Low Clarithromycin Resistance (<15%)

• PPI-clarithromycin-amoxicillin (PCA) triple therapy: PPI (standard dose twice daily), clarithromycin 500mg twice daily, amoxicillin 1g twice daily for 10-14 days 1, 2
• PPI-clarithromycin-metronidazole (PCM) triple therapy: PPI (standard dose twice daily), clarithromycin 500mg twice daily, metronidazole 500mg twice daily for 10-14 days 1
• Both PCA and PCM regimens are considered equivalent in efficacy 1

Areas with High Clarithromycin Resistance (>15-20%)

• Bismuth quadruple therapy: PPI (standard dose twice daily), bismuth subsalicylate/subcitrate (~300mg four times daily), metronidazole 500mg three times daily, tetracycline 500mg four times daily for 14 days 1, 2
• Sequential therapy: 5-day period with PPI plus amoxicillin, followed by 5-day period with PPI plus clarithromycin and metronidazole/tinidazole 1
• Non-bismuth quadruple therapy (concomitant): PPI, clarithromycin, amoxicillin, and metronidazole taken simultaneously 1, 2

Second-Line Treatment Options

• After failure of clarithromycin-containing therapy: bismuth-containing quadruple therapy or levofloxacin-containing triple therapy 1
• Levofloxacin triple therapy: PPI (standard dose twice daily), amoxicillin 1g twice daily, levofloxacin 500mg once daily or 250mg twice daily for 14 days 1, 2
• Rising rates of levofloxacin resistance should be considered when selecting this option 1

Third-Line Treatment Options

• After failure of second-line treatment, antimicrobial susceptibility testing should guide therapy whenever possible 1
• Options based on susceptibility testing may include:
  • Rifabutin triple therapy: rifabutin 150-300mg daily, amoxicillin 1g twice daily, PPI (standard dose twice daily) for 10 days 1
  • High-dose dual therapy: amoxicillin 2-3g daily in 3-4 split doses, PPI (high-dose twice daily) for 14 days 1

Optimization Strategies

• Using high-dose PPI (twice the standard dose) increases the efficacy of triple therapy 1
• Standard PPI doses: pantoprazole 40mg, lansoprazole 30mg, omeprazole 20mg, esomeprazole 20mg, dexlansoprazole 30mg, rabeprazole 20mg 1
• Extending treatment duration from 7 to 10-14 days improves eradication success by approximately 5% 1, 2
• PPI should be taken 30 minutes prior to eating on an empty stomach for optimal effect 1

Special Considerations

• For penicillin-allergic patients, amoxicillin can be replaced with metronidazole in triple therapy or alternative regimens should be considered 2
• Probiotics may help reduce treatment side effects but are not proven to increase eradication rates 1
• Confirmation of eradication should be performed using urea breath test or monoclonal stool antigen test 8 weeks after treatment completion 1, 2
• Serology is not appropriate for confirming eradication 1

Treatment Failures and Antibiotic Resistance

• Clarithromycin resistance is the most important factor affecting treatment success 1
• Patients with clarithromycin-resistant H. pylori should not receive clarithromycin-containing regimens 3
• After two failed therapies with confirmed patient adherence, H. pylori susceptibility testing should be considered 1
• Shared decision-making regarding ongoing attempts to eradicate H. pylori should weigh potential benefits against adverse effects, especially in vulnerable populations 1