What are the guidelines for treating H. pylori (Helicobacter pylori) infection?

Guidelines for Helicobacter pylori Treatment

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

First-Line Treatment Options

• Bismuth quadruple therapy for 14 days is the preferred first-line treatment regimen, consisting of:

  • Proton pump inhibitor (PPI) twice daily
  • Bismuth subsalicylate
  • Metronidazole
  • Tetracycline 3, 1

• In areas with low clarithromycin resistance (<15%), triple therapy may be considered:

  • PPI twice daily
  • Clarithromycin 500mg twice daily
  • Amoxicillin 1g twice daily (or metronidazole) for 14 days 1, 2

• Concomitant (non-bismuth quadruple) therapy is an alternative first-line option when bismuth is not available:

  • PPI
  • Clarithromycin
  • Amoxicillin
  • Metronidazole for 10-14 days 3, 1

Optimizing Treatment Success

• Use high-dose PPI (twice daily) to increase efficacy by reducing gastric acidity and enhancing antibiotic activity 1, 2

• Extend treatment duration to 14 days rather than 7-10 days to improve eradication rates by approximately 5% 1, 2

• Take medications at the start of a meal to minimize gastrointestinal intolerance 4

• For H. pylori triple therapy with amoxicillin, the FDA-approved adult dosing is 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 4

Second-Line Treatment Options

• After failure of first-line therapy, avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin 1, 2

• Recommended second-line options include:

  • Bismuth quadruple therapy (if not used as first-line)
  • Levofloxacin-based triple therapy (PPI, amoxicillin, levofloxacin) in areas with low levofloxacin resistance 3, 1

Third-Line and Rescue Therapies

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

• Alternative rescue therapies include:

  • Rifabutin-based triple therapy (PPI, amoxicillin, rifabutin)
  • High-dose dual amoxicillin-PPI therapy 3, 1

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 (from 9% in 1998 to over 15-20% in many regions), making traditional triple therapy less effective 1

• Avoid using clarithromycin-based triple therapy without prior susceptibility testing when clarithromycin resistance in the region exceeds 15-20% 1

• 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

• For dual therapy with amoxicillin, the FDA-approved adult dosing is 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days 4

• Diarrhea occurs in 21-41% of patients during the first week of H. pylori eradication therapy due to disruption of normal gut microbiota 1