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

Recommended Treatment for Helicobacter pylori Infection

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

First-Line Treatment Options

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

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, 3
• Take medications at the start of a meal to minimize gastrointestinal intolerance 4
• Probiotics can be used as adjunctive treatment to reduce side effects, particularly antibiotic-associated diarrhea 1, 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, 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 1, 2

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 1, 2
• In regions with clarithromycin resistance >15-20%, standard triple therapy should be abandoned due to unacceptably low eradication rates 1, 3
• Bismuth is valuable because bacterial resistance to this compound is extremely rare, making bismuth quadruple therapy effective even against strains resistant to metronidazole 1, 3

Third-Line and Rescue Therapies

• After two failed eradication attempts, antimicrobial susceptibility testing should guide further treatment whenever possible 1, 3
• Rifabutin-based triple therapy (PPI, amoxicillin, rifabutin) can be considered as a rescue option after multiple treatment failures 1, 3
• For patients with penicillin allergy, amoxicillin can be replaced with metronidazole in triple therapy regimens 1

Specific FDA-Approved Regimens

• Triple therapy: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days 4
• Dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days (for patients allergic or intolerant to clarithromycin or when resistance is suspected) 4

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 1, 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, 3
• Patients with renal impairment (GFR <30 mL/min) should not receive the 875 mg dose of amoxicillin 4
• Treatment duration of 14 days is now strongly recommended for all H. pylori eradication regimens due to increasing failure rates with shorter courses 1, 6