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

Recommended Dosing Regimens for Helicobacter pylori Infection Treatment

The recommended first-line empiric therapy for H. pylori infection is 14-day bismuth quadruple therapy consisting of bismuth (~300mg qid), metronidazole (500mg tid), tetracycline (500mg qid), and a PPI (bid) when antibiotic susceptibility is unknown. 1

First-Line Empiric Therapy Options

Bismuth Quadruple Therapy (14 days)

• Bismuth subsalicylate (e.g., PeptoBismol®) 2 tablets or 2 capsules qid 30 min before meals 1
• Tetracycline HCl 500 mg qid 30 min after meals 1
• Metronidazole 500 mg tid or qid 30 min after meals 1
• PPI bid 30 min before morning and evening meals 1

Rifabutin Triple Therapy (14 days)

• Rifabutin 150 mg bid 1
• Amoxicillin 1 g tid 1
• Esomeprazole or rabeprazole 40 mg bid 30 min before meals 1

Talicia® Formulation (14 days)

• As directed by package insert (contains rifabutin, amoxicillin, and omeprazole) 1

Susceptibility-Based Therapy Options

These regimens should only be used when susceptibility testing confirms >90% local eradication rates: 1

Clarithromycin Triple Therapy (14 days)

• Clarithromycin 500 mg bid 1
• Amoxicillin 1 g bid 30 min after meals 1
• PPI bid 30 min before meals 1

Metronidazole Triple Therapy (14 days)

• Metronidazole 500 mg bid 1
• Amoxicillin 1 g bid 30 min after meals 1
• PPI bid 30 min before meals 1

Levofloxacin Triple Therapy (14 days)

• Levofloxacin 500 mg once daily in morning 1
• Amoxicillin 1 g bid 30 min after meals 1
• PPI bid 30 min before meals 1

FDA-Approved Regimens for H. pylori Infection

Triple Therapy (14 days)

• Amoxicillin 1 gram bid 2
• Clarithromycin 500 mg bid 2
• Lansoprazole 30 mg bid 2

Dual Therapy (14 days)

• Amoxicillin 1 gram tid 2
• Lansoprazole 30 mg tid 2

Second-Line Therapy Options

After failure of first-line therapy: 1

• If clarithromycin-based therapy failed: Bismuth quadruple therapy for 14 days 1
• If bismuth quadruple therapy failed: Levofloxacin-based therapy or rifabutin triple therapy 1

Proton Pump Inhibitor Selection

• Higher-potency PPIs are recommended, especially with amoxicillin-containing regimens 1
• Recommended: 20-40 mg esomeprazole or rabeprazole bid 1
• Avoid pantoprazole due to lower relative potency 1
• Relative potency: 20 mg rabeprazole = 36 mg omeprazole; 20 mg esomeprazole = 32 mg omeprazole; 30 mg lansoprazole = 27 mg omeprazole; 40 mg pantoprazole = 9 mg omeprazole 1

Key Considerations

Duration of Therapy

• 14-day regimens are recommended for all H. pylori treatments to maximize eradication rates 1
• Some guidelines suggest 10-day regimens may be acceptable if proven locally to be as effective 1

Antibiotic Resistance

• Clarithromycin resistance rates >15-20% should prompt avoidance of clarithromycin-containing regimens 1
• Bismuth quadruple therapy is effective even against strains with metronidazole resistance 1
• After two failed therapies, antimicrobial susceptibility testing should be performed 1

Administration Timing

• PPI should be taken 30 minutes before eating on an empty stomach 1
• Avoid concomitant use of other antacids (e.g., H2-receptor antagonists) 1
• Bismuth and tetracycline should be taken 30 minutes before meals 1
• Antibiotics should be taken 30 minutes after meals 1

Common Pitfalls to Avoid

• Using clarithromycin-based regimens in areas with high clarithromycin resistance (>15%) 1
• Using shorter treatment durations (7-10 days) which result in lower eradication rates 1
• Using concomitant, sequential, hybrid, or reverse hybrid therapies which are now considered obsolete 1
• Using levofloxacin as first-line therapy (FDA recommends fluoroquinolones as last choice due to serious side effect risks) 1
• Using pantoprazole instead of higher-potency PPIs like esomeprazole or rabeprazole 1
• Failing to confirm eradication after treatment 1, 3