What are the recommended treatment regimens for H. pylori infection using branded medications that combine a Proton Pump Inhibitor (PPI) with antibiotics, such as Prevpac (lansoprazole, amoxicillin, and clarithromycin)?

Branded Combination Medications for H. pylori Treatment

Branded combination medications that package a PPI with antibiotics (such as Prevpac containing lansoprazole, amoxicillin, and clarithromycin) are no longer recommended as first-line therapy in most regions due to rising clarithromycin resistance rates exceeding 15-20%. 1, 2

Current Status of PPI-Clarithromycin Triple Therapy

The standard triple therapy regimen should be abandoned when regional clarithromycin resistance exceeds 15-20%. 1 This threshold has been surpassed in most of North America and Central, Western, and Southern Europe, where resistance rates now exceed 20%. 1, 2

Evidence of Declining Efficacy

• Clarithromycin resistance has increased globally from 9% in 1998 to 17.6% in 2008-2009, making traditional triple therapy achieve only 70% eradication rates in many regions—well below the 80% minimum target. 1
• When H. pylori strains are clarithromycin-resistant, eradication rates drop to approximately 20% compared to 90% with susceptible strains. 1
• Recent studies confirm this decline: a multicenter trial showed only 62-70% eradication rates with lansoprazole-clarithromycin-amoxicillin combinations. 3

When These Combinations May Still Be Appropriate

In regions with documented low clarithromycin resistance (<15%), PPI-clarithromycin-amoxicillin triple therapy for 14 days may be considered as first-line treatment. 1, 2 This applies primarily to Northern European countries where resistance remains below 10%. 1

Optimal Dosing When Used

If clarithromycin-based therapy is selected in low-resistance areas:

• Lansoprazole 30 mg + clarithromycin 500 mg + amoxicillin 1000 mg, all twice daily for 14 days achieves 94% eradication in intention-to-treat analysis when strains are susceptible. 4
• The 14-day duration is critical—extending from 7 to 14 days improves eradication by approximately 5%. 1, 2
• High-dose PPI (twice daily) is essential to reduce gastric acidity and enhance antibiotic activity. 1, 2

Recommended Alternatives to Branded Clarithromycin Combinations

Bismuth quadruple therapy for 14 days is now the preferred first-line treatment in areas with high clarithromycin resistance, achieving 80-90% eradication rates even against metronidazole-resistant strains. 2

Alternative First-Line Options

• Concomitant non-bismuth quadruple therapy: PPI twice daily + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily + metronidazole 500 mg twice daily for 14 days is recommended when bismuth is unavailable. 2
• This regimen avoids the pitfall of sequential therapy by administering all antibiotics simultaneously, preventing the development of resistance during treatment. 1

Critical Pitfalls to Avoid

• Never assume low clarithromycin resistance without local surveillance data—most regions now have high resistance rates. 1, 2
• Do not use 7-day regimens—they are inferior to 14-day courses regardless of the antibiotics chosen. 1, 2
• Avoid repeating clarithromycin if the patient has prior macrolide exposure (for any indication), as cross-resistance is universal within the macrolide family. 1, 2
• Standard-dose PPI once daily is inadequate—always use twice-daily dosing to maximize gastric pH elevation. 1, 2

Verification of Treatment Success

Confirm eradication with urea breath test or monoclonal stool antigen test at least 4 weeks after completing therapy and at least 2 weeks after discontinuing PPI. 2, 5 Serology should never be used for post-treatment confirmation as antibodies persist long after successful eradication. 5