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 and its high efficacy. 1, 2
First-Line Treatment Options
- In areas with high clarithromycin resistance (≥15-20%), bismuth quadruple therapy consisting of a PPI (twice daily), bismuth subsalicylate, metronidazole, and tetracycline for 14 days is the preferred first-line treatment 3, 1, 4
- In areas with low clarithromycin resistance (<15%), triple therapy using a PPI with clarithromycin and amoxicillin for 14 days may be considered, though bismuth quadruple therapy remains an effective alternative 3, 4, 2
- Concomitant (non-bismuth quadruple) therapy consisting of PPI, clarithromycin, amoxicillin, and metronidazole for 14 days is an alternative first-line option when bismuth is not available 4, 2
Optimizing Treatment Success
- High-dose PPI (twice daily) significantly increases eradication efficacy by 6-10% compared to standard doses by reducing gastric acidity and enhancing antibiotic activity 3, 1, 2
- Extending treatment duration to 14 days improves eradication success by approximately 5% compared to shorter regimens 3, 4, 2
- For H. pylori triple therapy, the FDA-approved regimen is 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 5
- For patients allergic or intolerant to clarithromycin, dual therapy with 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days is recommended 5
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 1, 4, 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, 6
- Rising rates of levofloxacin resistance should be taken into account when selecting second-line therapy 3, 6
Third-Line and Rescue Therapies
- After two failed eradication attempts, antimicrobial susceptibility testing should guide further treatment whenever possible 3, 1, 4
- Rifabutin-based triple therapy (PPI, amoxicillin, rifabutin) for 14 days is an effective rescue option after multiple treatment failures due to rare bacterial resistance 1, 4, 7
- High-dose dual therapy with amoxicillin and PPI is an alternative rescue therapy when other options have failed 4, 8
Treatment Selection Based on Antibiotic Resistance
- Clarithromycin resistance is the primary reason for triple therapy failure, with global resistance rates increasing from 9% in 1998 to 17.6% in 2008-2009 3, 4, 9
- In regions with clarithromycin resistance >15-20%, standard triple therapy should be abandoned due to unacceptably low eradication rates 3, 4, 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, 4, 2
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 3, 1, 2
- Serology should not be used to confirm eradication as antibodies may persist long after successful treatment 1, 2
Common Pitfalls and Caveats
- Inadequate PPI dosing significantly reduces H. pylori treatment efficacy; always use high-dose (twice daily) PPI 3, 1, 2
- Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin, to maximize the probability of successful eradication 1, 4, 2
- Probiotics can be used as adjunctive treatment to reduce side effects, particularly antibiotic-associated diarrhea, though evidence for increased eradication rates is limited 3, 2, 6
- Take medications at the start of a meal to minimize gastrointestinal intolerance 5