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

Recommended Medications for H. pylori Infection Treatment

Bismuth quadruple therapy for 14 days is the preferred first-line treatment for H. pylori infection due to increasing global clarithromycin resistance and its high efficacy. 1, 2, 3

First-Line Treatment Options

• Bismuth quadruple therapy (preferred): PPI (twice daily) + bismuth subsalicylate + metronidazole + tetracycline for 14 days 1, 2, 3
• In areas with low clarithromycin resistance (<15%): Triple therapy with PPI (twice daily) + clarithromycin 500mg BID + amoxicillin 1g BID for 14 days may be considered 1, 2
• Concomitant (non-bismuth quadruple) therapy: PPI + clarithromycin + amoxicillin + metronidazole for 10-14 days is an alternative first-line option when bismuth is not available 1, 2

Specific Dosing for First-Line Regimens

• Triple therapy: PPI (twice daily) + clarithromycin 500mg twice daily + amoxicillin 1g twice daily for 14 days 1, 4
• Dual therapy (FDA-approved): Amoxicillin 1g and lansoprazole 30mg, all given three times daily (every 8 hours) for 14 days 4

Treatment Selection Based on Antibiotic Resistance

• Clarithromycin resistance is the primary reason for triple therapy failure, with global resistance rates increasing significantly over time 1, 2
• 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 by reducing gastric acidity and enhancing antibiotic activity 1, 2
• Extending treatment duration to 14 days improves eradication success by approximately 5% compared to shorter regimens 1, 2
• Taking medications at the start of a meal minimizes potential gastrointestinal intolerance 4

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, 2, 5
• 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 1, 2

Third-Line and Rescue Therapies

• After two failed eradication attempts, antibiotic susceptibility testing should guide further treatment whenever possible 1, 2, 5
• Rifabutin-based triple therapy (PPI, amoxicillin, rifabutin) can be considered as a rescue option after multiple treatment failures 1, 6
• High-dose dual amoxicillin-PPI therapy is an alternative rescue therapy 1, 6

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, 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
• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin, to maximize the probability of successful eradication 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 due to disruption of normal gut microbiota 1
• Consider adjunctive probiotics to reduce the risk of diarrhea and improve patient compliance 1, 5