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

From the Guidelines

Helicobacter pylori infection should be treated with a 14-day course of bismuth quadruple therapy or clarithromycin-based triple therapy as the first-line treatment option. The treatment of H. pylori infection is crucial to prevent chronic gastritis, peptic ulcers, and gastric cancer. According to the most recent guidelines 1, the first-line treatment options include bismuth quadruple therapy, which consists of a proton pump inhibitor (PPI) such as omeprazole 20mg twice daily, bismuth subsalicylate 525mg four times daily, tetracycline 500mg four times daily, and metronidazole 500mg three times daily. Alternatively, clarithromycin-based triple therapy may be used, consisting of a PPI, clarithromycin 500mg twice daily, and amoxicillin 1g twice daily for 14 days 1.

Some key points to consider when treating H. pylori infection include:

• The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community 1
• Bismuth quadruple therapy is favored in areas with high dual resistance to clarithromycin and metronidazole 1
• Clarithromycin-based triple therapy is recommended as first-line therapy if low clarithromycin resistance is present 1
• Levofloxacin-based triple therapy is an option if first-line therapy fails, using a PPI, levofloxacin 500mg daily, and amoxicillin 1g twice daily for 10-14 days 1

It is essential to confirm treatment success with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and after stopping PPI medications for at least 2 weeks 1. Adherence to the full course of therapy is crucial for successful eradication, especially with rising antibiotic resistance 1.

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.

The treatment options for Helicobacter pylori (H. pylori) infection are:

• Triple therapy: Amoxicillin in combination with clarithromycin and lansoprazole
• Dual therapy: Amoxicillin in combination with lansoprazole, for patients who are allergic or intolerant to clarithromycin or have known or suspected resistance to clarithromycin 2

From the Research

Treatment Options for Helicobacter pylori (H. pylori) Infection

• The current approach to treating H. pylori infection involves a combination of two consecutive complementary treatments, with a first-line triple therapy consisting of a proton-pump inhibitor (PPI), clarithromycin, and amoxicillin for 7-10 days, followed by a quadruple therapy for treatment failures 3.
• Triple therapy, consisting of two antibiotics (clarithromycin and amoxicillin or metronidazole) in combination with a PPI, has become the first-line option for H. pylori infection, but approximately 20% of patients fail to achieve eradication with this treatment 4.
• Bismuth-based quadruple therapy is also a first-line regimen in areas with high clarithromycin and metronidazole resistance, and is the preferred second-line option otherwise 4.
• Other treatment options include:
  • Quadruple therapy as first-line therapy 3
  • Adjuvant lactoferrin with triple therapy 3
  • Sequential treatment with a PPI, clarithromycin, amoxicillin, and metronidazole 3
  • Concomitant nonbismuth quadruple therapy for 10-14 days 5
  • Tailored therapy based on antibiotic sensitivity testing, although this has limitations for clinical use 6
• New developments and future directions include the use of new antibiotic weapons, such as quinolones and rifamycin derivatives, and novel potassium-competitive acid blocker-based eradication regimens 3, 6.

Efficacy and Tolerability of Treatment Options

• The efficacy of concomitant nonbismuth quadruple therapy for 10 days was found to be similar to that of 14 days, with a higher tolerability rate for the 10-day regimen 5.
• A combination therapy of metronidazole, omeprazole, and clarithromycin was found to be effective in curing H. pylori infection, with a cure rate of 88% 7.
• Triple therapy with clarithromycin, amoxicillin, and a PPI has been shown to have a declining efficacy due to increasing antibiotic resistance 6.