What is the recommended treatment for H pylori infection?

H. pylori Treatment Recommendations

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

First-Line Treatment Options

Preferred Regimen: Bismuth Quadruple Therapy (14 days)

• PPI (proton pump inhibitor) twice daily (preferably esomeprazole or rabeprazole 40mg BID) 1
• Bismuth subsalicylate four times daily 2
• Metronidazole 500mg three to four times daily 2
• Tetracycline 500mg four times daily 2, 3

Alternative First-Line Options (Based on Local Resistance Patterns)

• In areas with low clarithromycin resistance (<15%): Triple therapy with PPI, clarithromycin 500mg BID, and amoxicillin 1g BID for 14 days 1, 2
• Rifabutin triple therapy: Rifabutin 150mg BID, amoxicillin 1g TID, plus esomeprazole or rabeprazole 40mg BID for 14 days 1

Treatment Selection Based on Antibiotic Resistance

• Choose therapy based on local clarithromycin resistance patterns:
  • Low resistance (<15%): Triple therapy may be considered 1
  • High resistance (≥15%): Bismuth quadruple therapy is preferred 1, 2
• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin 2

Optimizing Treatment Success

• Use high-dose PPI (twice daily) to increase efficacy by reducing gastric acidity and enhancing antibiotic activity 1
• Extend treatment duration to 14 days to improve eradication success by approximately 5% 1, 4
• Take PPI 30 minutes before meals to maximize acid suppression 1
• Consider probiotics as adjunctive treatment to reduce side effects and improve compliance 1, 2

Second-Line Treatment Options

• After failure of clarithromycin-containing therapy:
  • Bismuth quadruple therapy (if not previously used) 1, 2
  • Levofloxacin triple therapy: PPI BID, amoxicillin 1g BID, and levofloxacin 500mg daily or 250mg BID for 14 days 1, 3

Third-Line and Rescue Therapies

• After two failed eradication attempts, antimicrobial susceptibility testing is recommended whenever possible 1, 2
• Rifabutin-based triple therapy is effective as a rescue option after multiple treatment failures 2, 5
• High-dose dual therapy with amoxicillin and PPI can be considered for refractory cases 2

Verification of Eradication

• 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, 3
• Serology should not be used to confirm eradication 3

Common Pitfalls and Caveats

• Clarithromycin resistance is increasing globally (from 9% in 1998 to 17.6% in 2008-2009 in Europe), making traditional triple therapy less effective 1, 2
• Avoid concomitant, sequential, or hybrid therapies as they include unnecessary antibiotics that contribute to global antibiotic resistance 1
• In patients allergic to penicillin, amoxicillin can be replaced with metronidazole in triple therapy regimens 3
• The FDA recommends fluoroquinolones (like levofloxacin) be used as a last choice due to risk of serious side effects 1