Treatment of Erosive Antral Gastritis with Positive RUT
For erosive antral gastritis with confirmed H. pylori infection (RUT positive), initiate 14-day bismuth quadruple therapy as first-line treatment, consisting of a high-dose PPI (omeprazole 40 mg or equivalent twice daily), bismuth, tetracycline, and metronidazole. 1, 2
First-Line Treatment Regimen
Bismuth quadruple therapy is the preferred empirical first-line treatment for H. pylori eradication in the current era of rising antibiotic resistance 1. This regimen includes:
- High-dose PPI twice daily: Use omeprazole 40 mg, esomeprazole 20-40 mg, or rabeprazole 20-40 mg twice daily (avoid pantoprazole due to lower potency) 3
- Bismuth subsalicylate or bismuth subcitrate: Standard dosing four times daily 1, 2
- Tetracycline: 500 mg four times daily 2
- Metronidazole: 500 mg three times daily or 250 mg four times daily 4, 5
- Duration: 14 days 1, 2
The rationale for bismuth quadruple therapy is that bacterial resistance to bismuth is extremely rare, making this regimen effective even against clarithromycin-resistant strains 2.
Alternative First-Line Option (Region-Dependent)
In areas with documented low clarithromycin resistance (<15%), triple therapy may be considered, though this is increasingly uncommon 1. The regimen consists of:
- PPI: High-dose twice daily (omeprazole 40 mg or equivalent) 3
- Clarithromycin: 500 mg twice daily 6
- Amoxicillin: 1000 mg twice daily 6
- Duration: 10-14 days (14 days preferred for improved eradication rates) 4
However, standard triple therapy should be abandoned in regions with clarithromycin resistance >15-20% due to unacceptably low eradication rates 1.
Enhanced Quadruple Therapy Alternative
Concomitant quadruple therapy (all antibiotics simultaneously) for 5-10 days is another effective option 4:
- PPI: High-dose twice daily 3
- Amoxicillin: 1000 mg twice daily 4
- Clarithromycin: 500 mg twice daily 4
- Metronidazole: 500 mg twice daily 4
This achieves approximately 90% eradication rates compared to 80% with standard triple therapy 4.
Critical Treatment Optimization Factors
PPI Dosing
High-dose PPI (twice daily) is non-negotiable as it significantly increases eradication efficacy by 6-10% compared to standard doses 1, 2. The PPI reduces gastric acidity, promoting logarithmic phase bacterial growth and enhancing antibiotic penetration 3.
Treatment Duration
Extending treatment from 7 to 14 days improves eradication success by approximately 5-10% 1, 4. Always prescribe 14-day regimens when possible.
Antibiotic Selection
Avoid antibiotics the patient has previously received, particularly clarithromycin and levofloxacin, as resistance develops rapidly 2. Clarithromycin resistance has increased globally from 9% in 1998 to 17.6% in 2008-2009 1.
Second-Line Treatment After First-Line Failure
After failure of clarithromycin-containing therapy, use bismuth quadruple therapy (if not previously used) or levofloxacin-containing triple therapy 1:
- Levofloxacin triple therapy: PPI twice daily + amoxicillin 1000 mg twice daily + levofloxacin 500 mg once daily (or 250 mg twice daily) for 14 days 1
After two failed eradication attempts, antimicrobial susceptibility testing should guide further treatment whenever possible 2, 3. Culture and sensitivity testing is particularly important when endoscopy is performed for other indications 3.
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.
Do not use serology to confirm eradication as antibodies persist long after successful treatment 1, 2.
For erosive gastritis specifically, endoscopic follow-up may be warranted to document mucosal healing and exclude underlying malignancy, particularly in gastric (versus duodenal) erosions 3.
Common Pitfalls to Avoid
- Inadequate PPI dosing: This is the most common error; always prescribe twice-daily high-dose PPI 1, 2
- Testing too early: Wait at least 4 weeks post-treatment and 2 weeks off PPIs before testing for eradication 1, 2
- Using PPIs before diagnostic testing: PPIs should be stopped 2 weeks before RUT, histology, culture, or breath testing as they cause false-negative results 3
- Repeating failed antibiotics: Never reuse clarithromycin or levofloxacin after treatment failure 2
- Short treatment duration: Seven-day regimens are no longer adequate; use 14-day courses 1, 4
Special Considerations for Erosive Antral Gastritis
Erosive antral gastritis with H. pylori represents the duodenal ulcer phenotype, characterized by antral-predominant inflammation and high acid output 7. This pattern responds well to H. pylori eradication, which reduces both gastritis activity and erosion recurrence 7, 8.
The erosions themselves do not change the antibiotic regimen but emphasize the importance of successful eradication, as H. pylori-positive patients with erosions have a 38% recurrence rate at 17 years versus 11% in controls 7.