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

Recommended Therapy 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. 1, 2, 3

First-Line Treatment Options

Preferred Regimen

• Bismuth quadruple therapy for 14 days: PPI (twice daily) + bismuth subsalicylate + metronidazole + tetracycline 1, 3
• This regimen is effective even against strains resistant to metronidazole, as bacterial resistance to bismuth is extremely rare 1, 2

Alternative First-Line Options

• In areas with low clarithromycin resistance (<15-20%): Triple therapy with PPI + clarithromycin + amoxicillin (or metronidazole) for 10-14 days 1, 2
• Concomitant (non-bismuth quadruple) therapy: PPI + clarithromycin + amoxicillin + metronidazole for 10-14 days 1

Treatment Dosing for H. pylori

• Triple therapy: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 4
• Dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days 4
• High-dose PPI (twice daily) significantly increases the efficacy of eradication therapy by reducing gastric acidity and enhancing antibiotic activity 1, 2

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
• Clarithromycin resistance dramatically reduces treatment success rates from approximately 90% to 20% 2
• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin 1

Second-Line and Rescue Therapies

• After failed first-line therapy, an alternative regimen should be selected based on prior antibiotic exposure 1
• Levofloxacin-based triple therapy is an option after failure of clarithromycin-based treatment 2, 5
• Rifabutin-based triple therapy (PPI, amoxicillin, rifabutin) is effective as a rescue option after failed first-line treatment 1
• After two failed eradication attempts, antibiotic susceptibility testing is recommended to guide further treatment 1, 2

Optimizing Treatment Success

• Extending treatment duration from 7 to 14 days improves eradication success by approximately 5% 1, 2
• Taking medications at the start of a meal minimizes gastrointestinal intolerance 4
• Consider adding probiotics as adjunctive therapy to reduce side effects and improve patient compliance 1, 2

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

Common Pitfalls and Caveats

• Clarithromycin resistance is increasing globally, making traditional triple therapy less effective in many regions 6, 1, 2
• Treatment failure increases the risk of complications including gastric and peptic ulcers, gastric cancer, and MALT lymphoma 7, 8
• Diarrhea occurs in 21-41% of patients during the first week of H. pylori eradication therapy due to disruption of normal gut microbiota 1
• Serious and occasionally fatal hypersensitivity reactions have been reported in patients on penicillin therapy including amoxicillin 4