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

Treatment for 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 and its high efficacy. 1, 2

First-Line Treatment Options

• Bismuth quadruple therapy (preferred): PPI twice daily + bismuth subcitrate + metronidazole + tetracycline for 14 days 1, 2

• In areas with low clarithromycin resistance (<15%), triple therapy may be considered: PPI twice daily + clarithromycin 500mg BID + amoxicillin 1g BID for 14 days 1, 2

• For H. pylori with duodenal ulcer disease, FDA-approved regimens include:

  • Triple therapy: amoxicillin 1g + clarithromycin 500mg + lansoprazole 30mg, all twice daily for 14 days 3
  • Dual therapy: amoxicillin 1g + lansoprazole 30mg, each three times daily for 14 days 3

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, 2

Optimizing Treatment Success

• High-dose PPI (twice daily) significantly increases eradication efficacy by 6-10% compared to standard doses 2

• Extending treatment duration to 14 days improves eradication success by approximately 5% compared to shorter regimens 1, 2

• Take medications at the start of a meal to minimize gastrointestinal intolerance 3

Second-Line Treatment Options

• After failure of a clarithromycin-containing therapy, either bismuth quadruple therapy (if not previously used) or levofloxacin-containing triple therapy is recommended 2

• Levofloxacin-based triple therapy consists of a PPI twice daily, amoxicillin 1000 mg twice daily, and levofloxacin 500 mg once daily or 250 mg twice daily, for 14 days 2

• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin 1

Third-Line and Rescue Therapies

• After two failed eradication attempts, antimicrobial susceptibility testing should guide further treatment whenever possible 1, 2

• Rifabutin-based triple therapy (PPI, amoxicillin, rifabutin) can be considered as a rescue option after multiple treatment failures 1, 2, 4

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 2

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

Common Pitfalls and Caveats

• Inadequate PPI dosing significantly reduces H. pylori treatment efficacy; always use high-dose (twice daily) PPI 1, 2

• Clarithromycin resistance is increasing globally (from 9% in 1998 to 17.6% in 2008-2009), making traditional triple therapy less effective in many regions 1, 2

• In patients allergic to penicillin, amoxicillin can be replaced with tetracycline 2

• Diarrhea occurs in 21-41% of patients during the first week of H. pylori eradication therapy; consider adjunctive probiotics to reduce side effects and improve compliance 1

• In children, fluoroquinolones and tetracyclines should not be used, limiting treatment options 2