What is the treatment for Helicobacter pylori gastritis?

Treatment of Helicobacter pylori Gastritis

Bismuth quadruple therapy for 14 days is the recommended first-line treatment for H. pylori gastritis, consisting of a high-dose PPI (twice daily), bismuth subsalicylate, metronidazole, and tetracycline. 1, 2

First-Line Treatment Regimen

The optimal approach prioritizes succeeding on the first attempt to avoid retreatment, reduce costs, and minimize disruption to gut microbiota 1:

• Bismuth quadruple therapy for 14 days: PPI (esomeprazole 40 mg or rabeprazole 40 mg twice daily) + bismuth subsalicylate + metronidazole + tetracycline 1, 2
• This regimen achieves 80-90% eradication rates even against metronidazole-resistant strains due to bismuth's synergistic effects 2, 3
• Bismuth resistance is extremely rare, making this the most reliable empiric option 2, 3
• The 14-day duration is critical—it improves eradication by approximately 5% compared to shorter courses 2, 4

PPI Selection and Dosing

PPI potency varies significantly and directly impacts treatment success 1:

• Recommended: Esomeprazole 20-40 mg twice daily or rabeprazole 20-40 mg twice daily 1
• Avoid: Pantoprazole (significantly less potent: 40 mg pantoprazole = only 9 mg omeprazole equivalent) 1
• High-dose twice-daily PPI increases eradication efficacy by 6-10% by reducing gastric acidity and enhancing antibiotic activity 4, 3

Alternative First-Line Option (When Bismuth Unavailable)

• Concomitant non-bismuth quadruple therapy for 14 days: PPI (twice daily) + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily + metronidazole 500 mg twice daily 1, 2
• Use this only in regions where clarithromycin resistance is <15% 1, 2
• This regimen should NOT be used if the patient has had prior clarithromycin exposure 2, 3

Critical Caveat on Clarithromycin

• Clarithromycin resistance now exceeds 15% in most regions of North America and Europe 2, 4
• The WHO has identified H. pylori as requiring urgent antibiotic development due to high clarithromycin resistance 2
• Standard triple therapy (PPI + clarithromycin + amoxicillin) should be abandoned in most regions 1, 2

Second-Line Treatment (After First-Line Failure)

The choice depends on which antibiotics were used initially 1, 3:

• If clarithromycin was used first: Bismuth quadruple therapy for 14 days 1, 3
• If bismuth quadruple therapy was used first: Levofloxacin triple therapy (PPI twice daily + amoxicillin 1000 mg twice daily + levofloxacin 500 mg once daily) for 14 days 1, 4
• Never repeat antibiotics the patient has previously received, especially clarithromycin or levofloxacin 1, 2, 3

FDA Warning on Fluoroquinolones

• The FDA recommends fluoroquinolones (levofloxacin) be used as a last choice due to risk of serious side effects 1, 2
• Do not use levofloxacin empirically as first-line therapy due to rapidly rising resistance rates 2

Rescue Therapy (After Two Failed Attempts)

• Antibiotic susceptibility testing should guide treatment after two failures 1, 2, 3
• Rifabutin-based triple therapy: Rifabutin 150 mg twice daily + amoxicillin 1000 mg twice daily + PPI (twice daily) for 14 days 2, 3
• Rifabutin resistance is extremely rare, making it highly effective for persistent infections 2, 3
• High-dose dual therapy: Amoxicillin (high dose) + PPI (twice daily) is an alternative rescue option 1, 2

Regimens to Avoid

The most recent guidelines explicitly recommend against certain approaches 1:

• Do not use: Sequential therapy, hybrid therapy, or reverse hybrid therapy 1
• These regimens include unnecessary antibiotics that contribute to global antibiotic resistance without therapeutic benefit 1, 2
• Do not use: 7-day treatment courses—they are inferior to 14-day regimens 2, 4

Verification of Eradication

• Confirm eradication with urea breath test or monoclonal stool antigen test at least 4 weeks after completing therapy AND at least 2 weeks after stopping the PPI 2, 4, 3
• Never use serology to confirm eradication—antibodies persist long after successful treatment 4, 3

Common Pitfalls and How to Avoid Them

• Inadequate PPI dosing: Always use high-dose (twice daily) PPI; single daily dosing significantly reduces efficacy 4, 3
• Insufficient treatment duration: 14 days is superior to 7-10 days for all regimens 2, 4
• Repeating failed antibiotics: Document which antibiotics were used previously and avoid them in subsequent attempts 1, 2, 3
• Not confirming eradication: Treatment failure rates of 20-40% make confirmation testing mandatory 1, 4
• Poor medication timing: Amoxicillin should be taken at the start of meals to minimize gastrointestinal intolerance 5

Managing Side Effects

• Diarrhea occurs in 21-41% of patients during the first week due to gut microbiota disruption 2
• Consider adjunctive probiotics to reduce diarrhea risk and improve compliance 2
• Side effects overall occur in 15-30% of patients but are rarely severe enough to discontinue therapy 6