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

Treatment of Helicobacter pylori Infection

Bismuth quadruple therapy for 14 days is the preferred first-line treatment for H. pylori infection due to increasing global clarithromycin resistance and its high efficacy. 1, 2

First-Line Treatment Options

• Bismuth quadruple therapy (BQT) consists of:

  • Proton pump inhibitor (PPI) twice daily
  • Bismuth subsalicylate
  • Metronidazole
  • Tetracycline
  • Duration: 14 days 3, 1

• In areas with low clarithromycin resistance (<15%), triple therapy may be considered:

  • PPI twice daily
  • Clarithromycin 500 mg twice daily
  • Amoxicillin 1000 mg twice daily (or metronidazole if penicillin allergy)
  • Duration: 14 days 3, 4

• Concomitant (non-bismuth quadruple) therapy is another alternative:

  • PPI twice daily
  • Clarithromycin
  • Amoxicillin
  • Metronidazole
  • Duration: 14 days 1

Optimizing Treatment Success

• Always use high-dose PPI (twice daily) to increase eradication efficacy by 6-10% by reducing gastric acidity and enhancing antibiotic activity 4, 1

• Extend treatment duration to 14 days rather than 7 days to improve eradication rates by approximately 5% 3, 1

• Consider adding probiotics as adjunctive therapy to reduce side effects, particularly antibiotic-associated diarrhea 3, 1

• Take medications at the start of a meal to minimize gastrointestinal intolerance 5

Second-Line Treatment Options

• After failure of clarithromycin-containing therapy:

  • Use bismuth quadruple therapy (if not previously used) OR
  • Levofloxacin-based triple therapy:
    • PPI twice daily
    • Amoxicillin 1000 mg twice daily
    • Levofloxacin 500 mg once daily or 250 mg twice daily
    • Duration: 14 days 3, 1

• For patients previously treated with bismuth quadruple therapy:

  • Rifabutin triple therapy for 14 days is recommended 2

Third-Line and Rescue Therapies

• After two failed eradication attempts, antimicrobial susceptibility testing should guide therapy whenever possible 3, 1

• Rifabutin-based triple therapy (PPI, amoxicillin, rifabutin) can be considered as a rescue option after multiple treatment failures 1

• Potassium-competitive acid blocker dual therapy for 14 days is another alternative for treatment-naive patients without penicillin allergy 2

Verification of Eradication

• Confirm eradication with urea breath test or monoclonal stool antigen test:

  • At least 4 weeks after completion of therapy
  • At least 2 weeks after PPI discontinuation 4, 1

• Do not use serology to confirm eradication as antibodies may persist long after successful treatment 1

Common Pitfalls and Caveats

• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin, as resistance is likely to have developed 1

• 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 4, 1

• In regions with clarithromycin resistance >15-20%, standard triple therapy should be abandoned due to unacceptably low eradication rates 4, 1

• For patients allergic to penicillin, amoxicillin can be replaced with tetracycline 1

• In children, fluoroquinolones and tetracyclines should not be used, limiting treatment options 1

• Bismuth is valuable because bacterial resistance to this compound is extremely rare, making bismuth quadruple therapy effective even against strains resistant to metronidazole 1

• H. pylori treatment should not be delayed unnecessarily, as chronic infection increases the risk of peptic ulcer disease, gastric adenocarcinoma, and mucosa-associated lymphoid tissue lymphoma 6, 7