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

Recommended Treatment for H. 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. 1, 2, 3

First-Line Treatment Options

• Bismuth quadruple therapy: PPI twice daily + bismuth subsalicylate 524 mg four times daily + metronidazole + tetracycline for 14 days 1, 3
• In areas with low clarithromycin resistance (<15-20%), triple therapy may be considered: PPI + clarithromycin + amoxicillin (or metronidazole) for 10-14 days 4, 1
• Concomitant (non-bismuth quadruple) therapy: PPI + clarithromycin + amoxicillin + metronidazole for 10-14 days 4, 5

Treatment Selection Based on Antibiotic Resistance

• In regions with clarithromycin resistance >15-20%, standard triple therapy should be abandoned due to unacceptably low eradication rates 4, 1
• Bismuth is particularly valuable because bacterial resistance to this compound is extremely rare, making bismuth quadruple therapy effective even against strains resistant to metronidazole 1, 2
• For FDA-approved H. pylori treatment in the US, options include:
  • Triple therapy: 1 gram amoxicillin + 500 mg clarithromycin + 30 mg lansoprazole, all given twice daily for 14 days 6
  • Dual therapy: 1 gram amoxicillin + 30 mg lansoprazole, each given three times daily for 14 days 6

Optimizing Treatment Success

• High-dose PPI (twice daily) increases the efficacy of eradication therapy by reducing gastric acidity and enhancing antibiotic activity 4, 1
• Extending treatment duration from 7 to 14 days improves eradication success by approximately 5% 4, 3
• Patient compliance is critical for successful eradication; simplified regimens and management of side effects can improve adherence 1, 5
• Consider adjunctive probiotics to reduce side effects like diarrhea, which occurs in 21-41% of patients during treatment 1

Second-Line and Rescue Therapies

• After failure of first-line therapy, select an alternative regimen based on prior antibiotic exposure 1, 3
• Options include:
  • Levofloxacin-containing triple therapy (if not previously used and in areas with low levofloxacin resistance) 4, 5
  • Rifabutin-based triple therapy for 14 days 3
  • High-dose dual therapy with amoxicillin and PPI 1, 3
• After two failed eradication attempts, antibiotic susceptibility testing should guide further treatment 4, 1, 3

Common Pitfalls and Caveats

• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin 1, 2
• Clarithromycin resistance is increasing globally (from 9% in 1998 to 17.6% in 2008-2009 in Europe), making traditional triple therapy less effective 4
• Confirm eradication with urea breath test or monoclonal stool antigen test at least 4 weeks after completion of therapy and at least 2 weeks after PPI discontinuation 4, 1
• Patients with severe renal impairment (GFR <30 mL/min) should have amoxicillin dosing adjusted according to severity of renal dysfunction 6

The landscape of H. pylori treatment has evolved significantly due to increasing antibiotic resistance. While triple therapy was once the standard of care, bismuth quadruple therapy has emerged as the preferred first-line treatment in most regions due to its effectiveness against resistant strains and high eradication rates.