What is the standard regimen for Helicobacter pylori (H. pylori) pack therapy?

H. pylori Pack Therapy Prescription Guidelines

The recommended first-line H. pylori pack therapy is bismuth quadruple therapy for 14 days, consisting of a proton pump inhibitor (PPI) twice daily, bismuth subsalicylate, metronidazole, and tetracycline. 1, 2

First-Line Treatment Options

• Bismuth quadruple therapy (preferred first-line regimen):

  • PPI (standard dose) twice daily
  • Bismuth subsalicylate 524 mg (2 tablets) four times daily
  • Metronidazole 500 mg three times daily
  • Tetracycline 500 mg four times daily
  • Duration: 14 days 3, 1, 2

• Concomitant (non-bismuth quadruple) therapy (alternative when bismuth is unavailable):

  • PPI (standard dose) twice daily
  • Amoxicillin 1000 mg twice daily
  • Clarithromycin 500 mg twice daily
  • Metronidazole 500 mg twice daily
  • Duration: 10-14 days 3, 1

• Triple therapy (only in areas with low clarithromycin resistance <15%):

  • PPI (standard dose) twice daily
  • Amoxicillin 1000 mg twice daily
  • Clarithromycin 500 mg twice daily
  • Duration: 14 days 4

Second-Line Treatment Options

• Levofloxacin-based triple therapy:

  • PPI (standard dose) twice daily
  • Amoxicillin 1000 mg twice daily
  • Levofloxacin 500 mg once daily
  • Duration: 14 days 3, 2

• Bismuth quadruple therapy (if not used as first-line):

  • Same regimen as first-line bismuth quadruple therapy
  • Duration: 14 days 1, 2

Third-Line and Rescue Therapies

• Rifabutin-based triple therapy:

  • PPI (standard dose) twice daily
  • Amoxicillin 1000 mg twice daily
  • Rifabutin 150 mg twice daily
  • Duration: 14 days 1, 5

• High-dose dual therapy:

  • PPI (high dose) three times daily
  • Amoxicillin 1000 mg three times daily
  • Duration: 14 days 1, 2

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, 6
• Advise patients to take medications with meals to minimize gastrointestinal intolerance 4
• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin, as resistance is likely to have developed 3, 2

Important Considerations and Pitfalls

• Clarithromycin resistance is increasing globally, making traditional triple therapy less effective in many regions 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, 7
• Consider antimicrobial susceptibility testing after two treatment failures to guide further therapy 1, 8
• 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
• Probiotics may be considered as adjuvant therapy to reduce side effects and improve patient compliance 2, 8