From the Guidelines
If clarithromycin is not available for H. pylori treatment, the most effective alternative regimen is bismuth quadruple therapy, consisting of a proton pump inhibitor, bismuth subsalicylate, metronidazole, and tetracycline for 14 days, as recommended by recent guidelines 1. This regimen is preferred due to its high efficacy and ability to overcome antibiotic resistance. The bismuth quadruple therapy includes a proton pump inhibitor (such as omeprazole 20 mg twice daily), bismuth subsalicylate (525 mg four times daily), metronidazole (500 mg three times daily), and tetracycline (500 mg four times daily) for 14 days.
Alternative Regimens
Other alternative regimens include:
- Levofloxacin-based triple therapy, which includes a proton pump inhibitor (such as esomeprazole 40 mg twice daily), amoxicillin (1 gram twice daily), and levofloxacin (500 mg once daily) for 10-14 days, as suggested by 1.
- High-dose dual therapy, which includes a proton pump inhibitor (such as rabeprazole 20 mg four times daily) and amoxicillin (750 mg four times daily) for 14 days, as mentioned in 1.
Considerations for Penicillin Allergy
For patients allergic to penicillin, metronidazole can replace amoxicillin in these regimens. It is essential to note that the choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community, as highlighted in 1.
Treatment Success Confirmation
Treatment success should be confirmed with a urea breath test, stool antigen test, or endoscopy with biopsy at least 4 weeks after completing therapy and after stopping proton pump inhibitors for at least 2 weeks, as recommended by 1.
Mechanism of Action
These alternative treatments work by targeting the bacteria through different mechanisms - bismuth disrupts bacterial cell membranes, metronidazole and levofloxacin interfere with DNA synthesis, and tetracycline inhibits protein synthesis.
The most recent and highest quality study 1 supports the use of bismuth quadruple therapy as the first-line treatment for H. pylori infection, especially in the face of increasing antibiotic resistance.
From the FDA Drug Label
Adult Patients only Helicobacter pylori Infection and Duodenal Ulcer Disease: Triple therapy for Helicobacter pylori (H. pylori) with clarithromycin and lansoprazole : Amoxicillin, in combination with clarithromycin plus lansoprazole as triple therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) to eradicate H. pylori. Dual therapy for H. pylori with lansoprazole : Amoxicillin, in combination with lansoprazole delayed-release capsules as dual therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) who are either allergic or intolerant to clarithromycin or in whom resistance to clarithromycin is known or suspected.
Alternative treatments for H. pylori when Clarithromycin is not available include:
- Dual therapy with Amoxicillin and Lansoprazole, as indicated in the Amoxicillin label 2.
- Alternative antimicrobial therapy should be instituted if resistance to clarithromycin is demonstrated or susceptibility testing is not possible, as mentioned in the Omeprazole label 3.
From the Research
Alternative Treatments for H. pylori
When Clarithromycin is not available, several alternative treatments can be considered for Helicobacter pylori (H. pylori) infection. These include:
- Bismuth quadruple therapy 4
- Sequential therapy 4
- Non-bismuth quadruple (concomitant) therapy 4
- Dual-concomitant (hybrid) therapy 4
- Levofloxacin-based regimens, mainly designated as second-line/rescue options 4, 5, 6
Levofloxacin-Based Regimens
Levofloxacin demonstrates excellent bioavailability, widespread tissue and fluid distribution, extended half-life, limited drug interaction profile, low incidence of side effects, and remarkable activity against H. pylori with minimal primary resistance 5. A 10-day fluoroquinolone-based regimen consisting of a proton pump inhibitor, levofloxacin, and either amoxicillin or metronidazole has been shown to be effective in eradicating H. pylori infection 5, 6.
Other Treatment Options
Other treatment options for H. pylori infection include:
- Triple therapy based on levofloxacin and/or rifabutin mainly with combination of amoxicillin 6
- Bismuth-based quadruple therapy, which is the preferred second-line option in areas with high rates of clarithromycin and metronidazole resistance 6, 7
- Proton pump inhibitor (PPI)-based triple therapy regimens, which eradicate about 90% of H. pylori and are associated with mild side effects 7