What is the recommended treatment for a patient who is H pylori (Helicobacter pylori) positive?

Treatment of Helicobacter pylori Infection

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

First-Line Treatment Options

Bismuth Quadruple Therapy (Preferred)

• Bismuth quadruple therapy consisting of a PPI (twice daily), bismuth subcitrate, metronidazole, and tetracycline for 14 days is recommended as first-line treatment to maximize eradication efficacy 1, 2
• This regimen is particularly important in areas with high clarithromycin resistance (>15-20%) 3, 1
• No resistance to bismuth has been reported, making this regimen effective even against strains resistant to metronidazole 1, 2

Alternative First-Line Options (Only in Areas with Low Clarithromycin Resistance)

• In areas with low clarithromycin resistance (<15%), triple therapy using a PPI with clarithromycin and amoxicillin for 14 days may be considered 3, 1
• The standard triple therapy regimen includes:
  • PPI (high-dose, twice daily)
  • Clarithromycin (500mg twice daily)
  • Amoxicillin (1g twice daily) 1, 4, 5

Optimizing Treatment Success

• High-dose PPI (twice daily) increases efficacy by reducing gastric acidity and enhancing antibiotic activity 1, 2
• Extending treatment duration from 7 to 14 days improves eradication success by approximately 5% 3, 1
• Use the specific antibiotic indicated—clarithromycin for macrolides, tetracycline HCl (not doxycycline), and levofloxacin or moxifloxacin (not ciprofloxacin) for fluoroquinolones 3, 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-containing triple therapy is recommended as second-line therapy if first-line therapy failed 3, 1
• After two failed eradication attempts, antibiotic susceptibility testing is recommended to guide further treatment 3, 1
• Rifabutin-based triple therapy can be considered as a rescue option after multiple failed attempts 1, 2

Important Considerations and Caveats

• Clarithromycin resistance has increased globally from 9% in 1998 to 17.6% in 2008-2009 in Europe, making traditional triple therapy less effective 3, 1
• PPI-clarithromycin-containing triple therapy without prior susceptibility testing should be abandoned when clarithromycin resistance in the region exceeds 15-20% 3, 6
• 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 the risk of diarrhea and improve patient compliance 1

Treatment Duration

• The recommended duration for bismuth quadruple therapy is 14 days to maximize eradication rates 1, 2
• For triple therapy in areas with low clarithromycin resistance, 14-day regimens are preferred over 7-day regimens 1, 7

Antibiotic Resistance Patterns

• Clarithromycin resistance rates range from 10-34% globally (primary) and 15-67% (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

Remember that the choice of treatment regimen should be guided by local antibiotic resistance patterns whenever possible, with bismuth quadruple therapy being the most reliable option in most settings due to increasing clarithromycin resistance worldwide.