From the Guidelines
For H. pylori treatment in patients allergic to ciprofloxacin and trimethoprim-sulfamethoxazole (Septra), I recommend a bismuth quadruple therapy consisting of proton pump inhibitor (PPI) such as omeprazole 20mg twice daily, bismuth subsalicylate 525mg four times daily, tetracycline 500mg four times daily, and metronidazole 500mg three times daily for 14 days. This regimen is supported by the most recent guidelines, including the 2021 AGA clinical practice update on the management of refractory Helicobacter pylori infection 1. The bismuth quadruple therapy is a recommended first-line treatment, especially in areas with high dual resistance to clarithromycin and metronidazole, as it avoids the potential problem of antibiotic overuse and has acceptable success even in strains displaying in vitro metronidazole resistance 1.
Some key points to consider when using this regimen include:
- The importance of using a standard dose of PPI, unless high-dose is specifically stated, with optimal dosing 30 minutes prior to eating or drinking on an empty stomach, without concomitant use of other anti-acids 1
- The need to confirm eradication with either a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and at least 2 weeks after stopping PPI therapy
- The potential for substituting amoxicillin with metronidazole 500mg twice daily in penicillin-allergic patients who can't take amoxicillin
- The importance of patient adherence and proper dosing schedule in achieving treatment success
It's also worth noting that alternative regimens, such as concomitant therapy or levofloxacin triple therapy, may be considered in certain situations, but the bismuth quadruple therapy is generally the preferred option for patients with allergies to ciprofloxacin and trimethoprim-sulfamethoxazole (Septra) 1.
From the FDA Drug Label
2.4 Dosage for H. pylori Infection in Adults Triple therapy: The recommended adult oral dose is 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily (every 12 hours) for 14 days. Dual therapy: The recommended adult oral dose is 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily (every 8 hours) for 14 days.
The recommended treatment regimen for H. pylori infection is triple therapy or dual therapy, both of which include amoxicillin. However, the patient's allergies to ciprofloxacin and trimethoprim/sulfamethoxazole do not affect the recommended treatment regimens for H. pylori infection as listed, since neither ciprofloxacin nor trimethoprim/sulfamethoxazole are part of the recommended regimens.
- Triple therapy: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days.
- Dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days. 2