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

Recommended Treatment for 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, 3

First-Line Treatment Options

• In areas with high clarithromycin resistance (>15-20%), bismuth quadruple therapy is strongly recommended as first-line treatment 4, 1, 2
• Bismuth quadruple therapy consists of:
  • PPI (twice daily)
  • Bismuth subsalicylate
  • Metronidazole
  • Tetracycline
  • Duration: 14 days 1, 2, 3
• In areas with low clarithromycin resistance (<15%), triple therapy may be considered:
  • PPI (twice daily)
  • Clarithromycin (500mg twice daily)
  • Amoxicillin (1g twice daily)
  • Duration: 14 days 4, 1, 2

Optimizing Treatment Success

• Use high-dose PPI (twice daily) to increase eradication efficacy by 6-10% by reducing gastric acidity and enhancing antibiotic activity 4, 1, 3
• Extend treatment duration to 14 days to improve eradication success by approximately 5% compared to shorter regimens 4, 1, 2
• Consider probiotics as adjunctive treatment to reduce side effects, particularly antibiotic-associated diarrhea, though evidence for increased eradication rates is limited 4, 1, 3
• Take medications at the start of a meal to minimize gastrointestinal intolerance 5

Second-Line Treatment Options

• After failure of clarithromycin-containing therapy, use either:
  • Bismuth quadruple therapy (if not previously used) 4, 1, 2
  • Levofloxacin-containing triple therapy:
    • PPI (twice daily)
    • Amoxicillin (1g twice daily)
    • Levofloxacin (500mg once daily or 250mg twice daily)
    • Duration: 14 days 1, 2, 3

Third-Line and Rescue Therapies

• After two failed eradication attempts, antimicrobial susceptibility testing should guide further treatment whenever possible 4, 1, 2
• Rifabutin-based triple therapy (PPI, amoxicillin, rifabutin) can be considered as a rescue option after multiple treatment failures 1, 2
• For patients allergic to penicillin, amoxicillin can be replaced with tetracycline 4, 1

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, 2, 3
• Serology should not be used to confirm eradication as antibodies may persist long after successful treatment 1, 3

Common Pitfalls and Caveats

• 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, 3
• Inadequate PPI dosing significantly reduces H. pylori treatment efficacy; always use high-dose (twice daily) PPI 4, 1, 3
• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin 1, 2, 3
• In children, fluoroquinolones and tetracyclines should not be used, limiting treatment options 4, 1
• For dual therapy (when clarithromycin cannot be used), the FDA-approved regimen is amoxicillin (1g) and lansoprazole (30mg), each given three times daily for 14 days 5