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

Treatment of Helicobacter pylori Infection

Bismuth quadruple therapy for 14 days is the recommended first-line treatment for H. pylori infection due to increasing clarithromycin resistance globally. 1, 2, 3

First-Line Treatment Options

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

• Bismuth quadruple therapy: PPI (twice daily) + bismuth + tetracycline + metronidazole for 14 days is strongly recommended as first-line treatment 1, 2
• This regimen is effective even against strains resistant to metronidazole, as bacterial resistance to bismuth is extremely rare 1
• Concomitant (non-bismuth quadruple) therapy: PPI + clarithromycin + amoxicillin + metronidazole for 10-14 days is an alternative option 1

In Areas with Low Clarithromycin Resistance (<15-20%):

• Triple therapy may be considered: PPI + clarithromycin + amoxicillin (or metronidazole) for 10-14 days 1, 2
• Standard dosing for triple therapy includes 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 4
• High-dose PPI (twice daily) significantly increases the efficacy of clarithromycin-containing regimens 1, 2

Optimizing Treatment Success

• Extend treatment duration to 14 days to improve eradication success by approximately 5% 1, 2
• Take medications at the start of a meal to minimize gastrointestinal intolerance 4
• Consider adding probiotics as adjunctive therapy to reduce side effects and improve patient compliance 1
• 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 1

Second-Line Treatment Options

• After failed first-line therapy, an alternative regimen should be selected based on prior antibiotic exposure 1, 2
• If bismuth quadruple therapy was not used initially, it should be the preferred second-line option 1, 3
• Levofloxacin-containing triple therapy (PPI + amoxicillin + levofloxacin) is an effective second-line option if not previously used and in areas with low levofloxacin resistance 1, 5
• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin 1, 2

Third-Line and Rescue Therapies

• After two failed eradication attempts, antibiotic susceptibility testing is strongly recommended to guide further treatment 1, 2, 3
• Rifabutin-based triple therapy (PPI + amoxicillin + rifabutin) is effective as a rescue therapy after previous treatment failures 1, 3
• High-dose dual therapy with amoxicillin and PPI is an alternative option for refractory cases 1
• Consider antibiotics not previously used or for which resistance is unlikely, such as amoxicillin, tetracycline, bismuth, or furazolidone 6

Common Pitfalls and Considerations

• Clarithromycin resistance dramatically reduces treatment success rates from approximately 90% to 20% 2
• Antibiotic resistance rates are increasing globally, particularly for clarithromycin and metronidazole 1, 2
• Smoking and short duration of treatment are predictors of eradication failure 7
• Diarrhea occurs in 21-41% of patients during the first week of H. pylori eradication therapy due to disruption of normal gut microbiota 1
• The stomach's acidity affects antibiotic efficacy, which is why PPIs are a crucial component of all H. pylori treatment regimens 1