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

Treatment of Helicobacter pylori Infection

The recommended first-line treatment for H. pylori infection is bismuth-containing quadruple therapy for 14 days, especially in areas with high clarithromycin resistance (>15-20%). 1

First-line Treatment Options

In areas with high clarithromycin resistance (>15-20%):

• Bismuth-containing quadruple therapy for 14 days is the preferred first-line empirical treatment 1
• If bismuth quadruple therapy is unavailable, sequential treatment or non-bismuth quadruple therapy is recommended 1

In areas with low clarithromycin resistance (<15%):

• PPI-clarithromycin-amoxicillin or PPI-clarithromycin-metronidazole triple therapy for 14 days can be used 1
• Bismuth-containing quadruple therapy remains an effective alternative 1

Dosing considerations:

• High-dose PPI (twice daily) increases the efficacy of triple therapy 1
• Extending treatment duration from 7 to 14 days improves eradication success by approximately 5% 1
• For optimal results, use 40 mg of rabeprazole or esomeprazole twice daily rather than pantoprazole 1

Second-line Treatment Options

• After failure of PPI-clarithromycin-containing therapy, either bismuth-containing quadruple therapy or levofloxacin-containing triple therapy is recommended 1
• Rising rates of levofloxacin resistance should be considered when selecting second-line therapy 1

Third-line Treatment

• After failure of second-line therapy, treatment should be guided by antimicrobial susceptibility testing whenever possible 1
• Rifabutin triple therapy for 14 days is an option for patients who have failed previous treatments 1

Treatment for Patients with Penicillin Allergy

• In areas of low clarithromycin resistance, PPI-clarithromycin-metronidazole combination may be prescribed 1
• In areas of high clarithromycin resistance, bismuth-containing quadruple therapy is preferred 1
• As a rescue regimen in areas of low fluoroquinolone resistance, a levofloxacin-containing regimen can be used 1

Confirmation of Eradication

• Confirmation of H. pylori eradication should be performed at least 4 weeks after completing treatment 1
• The urea breath test (UBT) or a laboratory-based validated monoclonal stool test are recommended as non-invasive tests for determining treatment success 1
• Endoscopy-based testing is necessary for patients with complicated peptic ulcer disease, gastric ulcer, and MALT lymphoma 1

Indications for H. pylori Eradication

• All patients with peptic ulcer disease (active or history) 1
• First-degree relatives of family members with gastric cancer 1
• Patients with previous gastric neoplasia treated by endoscopic or subtotal gastric resection 1
• Patients with severe pan-gastritis, corpus-predominant gastritis, or severe atrophy 1
• Patients requiring chronic gastric acid inhibition for more than 1 year 1
• Patients with strong environmental risk factors for gastric cancer 1

Important Considerations

• Antibiotic resistance is the most important factor responsible for the falling success rate of H. pylori eradication treatment 1
• Local surveillance of H. pylori antibiotic resistance is mandatory, and treatment should be chosen according to local resistance patterns 1
• Patient compliance is crucial for successful eradication 2
• Avoid using antibiotics to which the patient has been previously exposed 2

Pitfalls to Avoid

• Do not use clarithromycin-containing regimens empirically when local clarithromycin resistance exceeds 15-20% 1
• Avoid monotherapy with antibiotics as this increases the risk of resistance 1
• Do not use levofloxacin in patients with chronic infectious bronchopneumopathy who may have received fluoroquinolones previously 1
• Confirm eradication especially in cases of complicated peptic ulcer, gastric ulcer, and MALT lymphoma 1

By following these evidence-based recommendations, H. pylori eradication can be achieved in most patients, reducing the risk of peptic ulcer recurrence and potentially decreasing the risk of gastric cancer in high-risk populations.