From the Guidelines
Azithromycin is not a recommended first-line treatment for Helicobacter pylori infection due to increasing resistance rates, and its use should be considered only as part of a rescue therapy regimen when standard treatments have failed, as suggested by the 2021 expert review in Gastroenterology 1.
Treatment Approach
When considering azithromycin as part of a rescue therapy, it's crucial to understand that the primary cause of refractory H. pylori infection is often antibiotic resistance, and providers should attempt to identify other contributing etiologies, including inadequate adherence to therapy and insufficient gastric acid suppression 1.
Key Considerations
- Antibiotic Resistance: A history of macrolide or fluoroquinolone use should prompt avoidance of clarithromycin- or levofloxacin-based regimens due to high resistance likelihood 1.
- Adherence and Education: Barriers to adherence should be explored, and patients should be educated on the rationale for therapy, dosing, expected adverse events, and the importance of completing the full therapeutic course 1.
- Dosing and Combination: If used, azithromycin should be part of a regimen that includes a proton pump inhibitor (PPI) and another antibiotic, with consideration for high-dose PPIs and divided dosing of antibiotics like amoxicillin to avoid low trough levels and improve eradication rates 1.
- Treatment Duration: Longer treatment durations, such as 14 days, are associated with higher eradication success rates compared to shorter durations 1.
Recommendations for Practice
- Testing and Confirmation: Patients should undergo testing to confirm H. pylori infection before treatment and have follow-up testing at least 4 weeks after therapy to confirm eradication, while off PPIs for at least 2 weeks.
- Penicillin Allergy Testing: In patients labeled as having a penicillin allergy without a history of anaphylaxis, consider penicillin allergy testing to potentially enable the use of amoxicillin 1.
- Acid Suppression: Inadequate acid suppression can undermine eradication efforts; thus, optimal dosing of PPIs, including the use of more potent PPIs or potassium-competitive acid blockers if available, should be considered 1.
From the Research
Treatment for Helicobacter pylori (H. pylori) Infection using Azithromycin
- The treatment for H. pylori infection using azithromycin involves a combination of azithromycin with other antibiotics and a proton pump inhibitor (PPI) 2, 3.
- A study published in 1996 found that triple therapy with azithromycin, omeprazole, and amoxicillin was highly effective in eradicating H. pylori, with a success rate of 91.6% 2.
- Another study published in 1998 found that a regimen of omeprazole, azithromycin, and either amoxicillin or metronidazole was effective in eradicating H. pylori in patients with duodenal ulcers, with a success rate of 85% for the amoxicillin group and 74% for the metronidazole group 3.
- However, more recent studies have not specifically mentioned azithromycin as a recommended treatment for H. pylori infection, instead recommending concomitant nonbismuth quadruple therapy or traditional bismuth quadruple therapy as first-line treatments 4.
- A meta-analysis published in 2020 compared the efficacy of proton-pump inhibitor and amoxicillin-based triple therapy containing clarithromycin versus metronidazole for H. pylori, but did not include azithromycin as one of the treatment options 5.
Dosage and Duration of Azithromycin Treatment
- The dosage of azithromycin used in the studies was 500 mg, taken either once daily for 3 days 2 or once daily for 6 days 3.
- The duration of treatment varied, with one study using a 14-day treatment period 2 and another using a 10-day treatment period for the antibiotics, with omeprazole continued for a total of 42 days 3.