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

Current Recommended H. pylori Treatment

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

First-Line Treatment Options

• Bismuth quadruple therapy (14 days): PPI twice daily + bismuth subsalicylate + metronidazole + tetracycline 1, 2
• In areas with low clarithromycin resistance (<15%), triple therapy may still be considered: PPI + clarithromycin + amoxicillin (or metronidazole) for 14 days 1, 2
• Concomitant (non-bismuth quadruple) therapy: PPI + clarithromycin + amoxicillin + metronidazole for 10-14 days is an alternative first-line option 1

Treatment Selection Based on Antibiotic Resistance

• In regions with clarithromycin resistance >15-20%, standard triple therapy should be abandoned due to unacceptably low eradication rates 1, 2
• Bismuth is valuable because bacterial resistance to this compound is extremely rare, making bismuth quadruple therapy effective even against strains resistant to metronidazole 1

Optimizing Treatment Success

• High-dose PPI (twice daily) increases the efficacy of eradication therapy by reducing gastric acidity and enhancing antibiotic activity 1, 2
• Extending treatment duration to 14 days rather than 7-10 days improves eradication success by approximately 5% 1, 2
• The stomach's acidity affects antibiotic efficacy, which is why PPIs are a crucial component of all H. pylori treatment regimens 1

Second-Line Treatment Options

• After failure of first-line therapy, an alternative regimen should be selected based on prior antibiotic exposure 1, 2
• Levofloxacin-containing triple therapy (PPI + amoxicillin + levofloxacin) is recommended as second-line treatment if not previously used 1, 2
• If bismuth quadruple therapy was not used as first-line, it should be considered as second-line therapy 1, 2

Third-Line and Rescue Therapies

• After two failed eradication attempts, antibiotic susceptibility testing is strongly recommended to guide further treatment 1, 2
• Rifabutin-based triple therapy (PPI + amoxicillin + rifabutin) is an effective rescue option after multiple treatment failures 1, 2
• High-dose dual therapy with amoxicillin and PPI is another option for refractory cases 1

FDA-Approved Regimens

• Triple therapy: Amoxicillin + clarithromycin + lansoprazole is FDA-approved for H. pylori eradication 3, 4, 3
• Dual therapy: Amoxicillin + lansoprazole is approved for patients who are allergic or intolerant to clarithromycin or in whom resistance is known or suspected 3, 4, 3

Common Pitfalls and Caveats

• Clarithromycin resistance is increasing globally, making traditional triple therapy less effective in many regions 1, 2
• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin 1, 2
• 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
• Diarrhea occurs in 21-41% of patients during the first week of H. pylori eradication therapy due to disruption of normal gut microbiota 1
• Consider adjunctive probiotics to reduce side effects and improve patient compliance 1, 5, 6

Antibiotic Resistance Patterns

• Clarithromycin resistance rates range from 10-34% globally (primary) and 15-67% (secondary) 1
• Levofloxacin resistance rates range from 11-30% (primary) and 19-30% (secondary) 1
• Metronidazole resistance rates range from 23-56% (primary) and 30-65% (secondary) 1
• Amoxicillin and tetracycline resistance rates remain low at 1-5% 1