What antibiotics are given for H. pylori positive patients?

Antibiotics for H. pylori Positive Patients

For H. pylori positive patients, the recommended first-line treatment is triple therapy consisting of a proton pump inhibitor (PPI) plus clarithromycin (500 mg) plus either amoxicillin (1 g) or metronidazole (500 mg) given twice daily for 14 days. 1

First-Line Treatment Options

Triple Therapy

• PPI + clarithromycin (500 mg) + amoxicillin (1 g), all twice daily for 14 days 1, 2
• PPI + clarithromycin (500 mg) + metronidazole (500 mg), all twice daily for 14 days (for penicillin-allergic patients) 1
• Amoxicillin is preferred for patients previously treated with metronidazole 1
• Metronidazole is preferred for patients with penicillin allergy 1

Bismuth-Based Quadruple Therapy

• In areas of high clarithromycin resistance (>15%), bismuth-containing quadruple therapy is recommended as first-line treatment 1
• Regimen: bismuth subsalicylate (2 tablets QID) + metronidazole (250 mg QID) + tetracycline (500 mg QID) + PPI (BID) for 14 days 1

Treatment Duration

• 14-day regimens are recommended as they provide higher eradication rates compared to 7-day regimens 1
• Longer treatment durations significantly improve eradication success rates 1

Considerations for Treatment Selection

Antibiotic Resistance

• Local antibiotic resistance patterns should guide treatment selection 1
• Clarithromycin resistance is a major cause of treatment failure and is increasing worldwide 1, 3
• Antibiotic combinations should be chosen according to local H. pylori resistance patterns 1

Patient-Specific Factors

• Prior antibiotic exposure should be reviewed to avoid using antibiotics where resistance may have developed 1, 3
• For patients with penicillin allergy, clarithromycin + metronidazole + PPI is recommended in areas of low clarithromycin resistance 1
• In penicillin-allergic patients in areas with high clarithromycin resistance, bismuth quadruple therapy is preferred 1

Second-Line Treatment Options

• After failure of clarithromycin-based triple therapy, bismuth quadruple therapy is recommended 1, 4
• Levofloxacin-based triple therapy (PPI + amoxicillin + levofloxacin) is an effective second-line option 1, 4
• Rifabutin-based regimens may be considered after multiple treatment failures 1

Confirmation of Eradication

• Eradication should be confirmed at least 4 weeks after treatment completion 1
• Urea breath test (UBT) or monoclonal stool antigen test are recommended for confirming eradication 1
• Antibiotics should be withheld for at least 4 weeks and PPIs for at least 2 weeks before testing 1

Common Pitfalls to Avoid

• Using clarithromycin in patients with prior macrolide exposure (high risk of resistance) 1, 3
• Inadequate acid suppression (use high-dose and more potent PPIs) 1
• Poor patient adherence due to complex regimens and side effects 1
• Using serology tests to confirm eradication (antibody levels remain elevated after H. pylori elimination) 1
• Insufficient treatment duration (shorter than 14 days) 1

Special Considerations

• For MALT lymphoma patients, H. pylori eradication is the first-line treatment regardless of stage 1
• H. pylori eradication reduces the risk of gastric cancer, especially in high-risk populations 1
• In patients with multiple treatment failures, antimicrobial susceptibility testing should guide further treatment 1

Remember that antibiotic resistance is the most important factor affecting treatment success, and local resistance patterns should always be considered when selecting an appropriate regimen 1.