H. pylori Treatment Recommendations
Bismuth quadruple therapy for 14 days is the recommended first-line treatment for H. pylori infection, consisting of a PPI twice daily, bismuth subsalicylate, metronidazole, and tetracycline. 1, 2
Why Bismuth Quadruple Therapy is Preferred
Clarithromycin resistance now exceeds 15% in most regions of North America, making traditional triple therapy unacceptably ineffective with eradication rates dropping from 90% to 20% in resistant strains 1, 3
Bismuth quadruple therapy achieves eradication rates of 80-90% even against metronidazole-resistant strains due to the synergistic effect of bismuth with other antibiotics 1
Bacterial resistance to bismuth is extremely rare, which is why this regimen remains highly effective 1
From an antimicrobial stewardship perspective, bismuth quadruple therapy uses antibiotics from the WHO "Access group" (tetracycline and metronidazole) rather than the "Watch group" (clarithromycin, levofloxacin), making it preferable for preserving antibiotic effectiveness 1
Treatment Duration and Dosing
The treatment duration must be 14 days to maximize eradication rates - shorter courses of 7-10 days are a common mistake that reduces efficacy by approximately 5% 1, 3, 4
Use high-dose PPI twice daily (not once daily) to reduce gastric acidity and enhance antibiotic activity 1, 3
Higher doses of metronidazole (1.5-2 g daily in divided doses) improve eradication rates even with resistant strains when combined with bismuth 1
Alternative First-Line Options (When Bismuth is Unavailable)
Concomitant non-bismuth quadruple therapy: PPI twice daily + amoxicillin 1000 mg twice daily + metronidazole 500 mg twice daily + clarithromycin 500 mg twice daily for 14 days 1
Rifabutin triple therapy: Rifabutin 150 mg twice daily + amoxicillin 1000 mg twice daily + PPI twice daily for 14 days (acceptable alternative in patients without penicillin allergy, as resistance to rifabutin and amoxicillin remains rare) 1, 2
Triple therapy only in low resistance areas: PPI + clarithromycin 500 mg twice daily + amoxicillin 1000 mg twice daily for 14 days may be considered ONLY in regions where clarithromycin resistance is documented to be <15% 1, 3
FDA-Approved Dosing for H. pylori
Triple therapy: 1 gram amoxicillin + 500 mg clarithromycin + 30 mg lansoprazole, all given twice daily for 14 days 5
Dual therapy: 1 gram amoxicillin + 30 mg lansoprazole, each given three times daily for 14 days (for patients allergic or intolerant to clarithromycin) 5
Critical Pitfalls to Avoid
Never repeat antibiotics to which the patient has been previously exposed, especially clarithromycin and levofloxacin, as resistance is likely to have developed 1, 3, 4
Do not use levofloxacin empirically as first-line therapy due to rapidly rising fluoroquinolone resistance rates and FDA warnings about serious side effects 1
Avoid prescribing standard triple therapy in areas where clarithromycin resistance exceeds 15-20% - this is the most common mistake made by European gastroenterologists (46% of cases) 1, 4
Do not assume penicillin allergy without verification - consider penicillin allergy testing to enable amoxicillin use, as amoxicillin resistance remains rare at only 1-5% 1
After Treatment Failure
After first treatment failure: Use optimized bismuth quadruple therapy for 14 days if not previously used 2
After two failed eradication attempts: Antibiotic susceptibility testing is mandatory to guide further treatment 1, 3, 2
Rifabutin-based therapy should be reserved as a rescue option after failed first-line treatment, not as initial therapy 1, 2
Levofloxacin-containing triple therapy is a second-line option only if not previously used and in areas with low levofloxacin resistance 1, 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, 3
Failing to check eradication success is a critical error made in 6% of cases 4