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

Treatment of Helicobacter pylori Infection in Westchester County, NY

Bismuth quadruple therapy for 14 days is the recommended first-line treatment for H. pylori infection in Westchester County, NY, due to high clarithromycin resistance patterns in the United States. 1, 2

First-Line Treatment Regimen

• Bismuth quadruple therapy consists of:

  • Proton pump inhibitor (PPI) twice daily
  • Bismuth subsalicylate
  • Metronidazole
  • Tetracycline
  • Duration: 14 days 1, 2

• This regimen is particularly effective because bacterial resistance to bismuth is extremely rare, making it effective even against strains resistant to other antibiotics 1, 2

• High-dose PPI (twice daily) should be used to increase efficacy by reducing gastric acidity and enhancing antibiotic activity 2, 3

Alternative First-Line Options

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

  • PPI twice daily
  • Clarithromycin 500mg twice daily
  • Amoxicillin 1g twice daily
  • Duration: 14 days 1, 3

• However, clarithromycin resistance is increasing globally, making traditional triple therapy less effective in many regions, including most of the United States 3

Second-Line Treatment Options

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

• Levofloxacin-based triple therapy is recommended as a second-line option:

  • PPI twice daily
  • Amoxicillin 1g twice daily
  • Levofloxacin
  • Duration: 10-14 days 2, 3

• Note that FDA recommends fluoroquinolones (like levofloxacin) be used as a last choice due to risk of serious side effects 1

Third-Line and Rescue Therapies

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

• Rifabutin-based triple therapy is an effective rescue option:

  • PPI twice daily
  • Amoxicillin 1g twice daily
  • Rifabutin
  • Duration: 14 days 1, 4

• High-dose dual therapy with amoxicillin and PPI is another alternative for refractory cases 1

Specific FDA-Approved Regimens

• Triple therapy (FDA-approved):

  • 1 gram amoxicillin
  • 500 mg clarithromycin
  • 30 mg lansoprazole
  • All given twice daily for 14 days 5

• Dual therapy (FDA-approved):

  • 1 gram amoxicillin
  • 30 mg lansoprazole
  • All given three times daily for 14 days 5

Verification of Eradication

• Confirm eradication with urea breath test or monoclonal stool antigen test:
  • At least 4 weeks after completion of therapy
  • At least 2 weeks after PPI discontinuation 1, 2

Common Pitfalls and Considerations

• Clarithromycin resistance dramatically reduces treatment success rates from approximately 90% to 20% 3

• Extending treatment duration to 14 days rather than 7 days improves eradication rates by approximately 5% 2, 3

• Consider adding probiotics as adjuvant therapy to reduce side effects like diarrhea (occurs in 21-41% of patients) and improve patient compliance 1, 2

• Patients with severe renal impairment (GFR <30 mL/min) require dose adjustments for amoxicillin 5

• Avoid repeating antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin, as resistance is likely to have developed 2, 3