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

Recommended Treatment for Helicobacter pylori Infection

The recommended first-line treatment for H. pylori infection is 14-day bismuth quadruple therapy, consisting of a proton pump inhibitor (PPI) twice daily, bismuth subsalicylate four times daily, metronidazole 500 mg three or four times daily, and tetracycline 500 mg four times daily, especially in areas with high clarithromycin resistance (≥15%). 1, 2, 3

First-Line Treatment Options

• Bismuth quadruple therapy for 14 days is the preferred first-line treatment due to increasing global clarithromycin resistance and its high efficacy 1, 2
• In areas with low clarithromycin resistance (<15%), triple therapy using a PPI with clarithromycin and amoxicillin (or metronidazole) for 14 days may be considered 1, 2
• Concomitant (non-bismuth quadruple) therapy consisting of PPI, clarithromycin, amoxicillin, and metronidazole for 14 days is an alternative first-line option 2

Optimizing Treatment Success

• High-dose PPI (twice daily) significantly increases eradication efficacy by 6-10% compared to standard doses by reducing gastric acidity and enhancing antibiotic activity 1, 2
• Extending treatment duration to 14 days improves eradication success by approximately 5% compared to shorter regimens 1, 3
• The use of probiotics as adjunctive treatment can help reduce side effects, particularly antibiotic-associated diarrhea, though evidence for increased eradication rates is limited 1, 2

Second-Line Treatment Options

• After failure of a clarithromycin-containing therapy, either bismuth quadruple therapy (if not previously used) or levofloxacin-containing triple therapy is recommended 1, 3
• Levofloxacin-based triple therapy consists of a PPI twice daily, amoxicillin 1000 mg twice daily, and levofloxacin 500 mg once daily or 250 mg twice daily, for 14 days 3
• FDA-approved dual therapy option: amoxicillin 1 gram and lansoprazole 30 mg, each given three times daily (every 8 hours) for 14 days, for patients allergic or intolerant to clarithromycin 4

Treatment Selection Based on Antibiotic Resistance

• Clarithromycin resistance is the primary reason for triple therapy failure, with global resistance rates increasing from 9% in 1998 to 17.6% in 2008-2009 1, 2
• In regions with clarithromycin resistance >15-20%, standard triple therapy should be abandoned due to unacceptably low eradication rates 1, 2
• Bismuth is valuable because bacterial resistance to this compound is extremely rare, making bismuth quadruple therapy effective even against strains resistant to metronidazole 2

Third-Line and Rescue Therapies

• After two failed eradication attempts, antimicrobial susceptibility testing should guide further treatment whenever possible 1, 2
• Rifabutin-based triple therapy (PPI, amoxicillin, rifabutin) can be considered as a rescue option after multiple treatment failures 2, 5
• High-dose dual therapy with amoxicillin and PPI is another option for refractory cases 2, 6

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 as antibodies may persist long after successful treatment 1

Common Pitfalls and Caveats

• Inadequate PPI dosing significantly reduces H. pylori treatment efficacy; always use high-dose (twice daily) PPI 1, 2
• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin, to maximize the probability of successful eradication 2
• Patient compliance is crucial for successful eradication; educate patients about the importance of completing the full course of treatment despite potential side effects 7
• In patients allergic to penicillin, amoxicillin can be replaced with tetracycline 3
• In children, fluoroquinolones and tetracyclines should not be used, limiting treatment options 8