What is the treatment for Helicobacter pylori (H. pylori) infection?

From the Guidelines

The recommended first-line treatment for H. pylori infection is a standard triple therapy regimen consisting of a proton pump inhibitor (PPI), amoxicillin, and clarithromycin, for 14 days, as this approach has been shown to be effective in eradicating the infection and reducing the risk of recurrent bleeding and other complications 1.

Key Considerations

• The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community, as the response to eradication therapy is significantly related to the prevalence of primary resistance in the population 1.
• In areas with low clarithromycin resistance, standard triple therapy is recommended as first-line therapy, with suggested doses including PPI standard dose twice a day, clarithromycin 500 mg twice a day, and amoxicillin 1000 mg twice a day 1.
• For patients with high clarithromycin resistance, sequential therapy with four drugs (amoxicillin, clarithromycin, metronidazole, and PPI) or levofloxacin-based triple therapy may be considered as alternative options 1.

Treatment Regimens

• Standard triple therapy: PPI, amoxicillin, and clarithromycin for 14 days
• Sequential therapy: PPI and amoxicillin for the first 5 days, followed by PPI, clarithromycin, and metronidazole for the next 5 days
• Levofloxacin-based triple therapy: PPI, amoxicillin, and levofloxacin for 10-14 days

Important Notes

• Treatment is important because H. pylori causes chronic gastritis and increases risk for peptic ulcers and gastric cancer 1.
• After completing treatment, patients should be tested to confirm eradication, typically using a urea breath test or stool antigen test at least 4 weeks after therapy and after stopping PPI for at least 2 weeks 1.

From the FDA Drug Label

Adult Patients only Helicobacter pylori Infection and Duodenal Ulcer Disease: Triple therapy for Helicobacter pylori (H. pylori) with clarithromycin and lansoprazole : Amoxicillin, in combination with clarithromycin plus lansoprazole as triple therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) to eradicate H. pylori. Dual therapy for H. pylori with lansoprazole : Amoxicillin, in combination with lansoprazole delayed-release capsules as dual therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) who are either allergic or intolerant to clarithromycin or in whom resistance to clarithromycin is known or suspected.

H. Pylori Treatment: Amoxicillin is indicated for the treatment of H. pylori infection in combination with other medications.

• Triple Therapy: Amoxicillin can be used in combination with clarithromycin and lansoprazole to treat H. pylori infection and duodenal ulcer disease.
• Dual Therapy: Amoxicillin can also be used in combination with lansoprazole for patients who are allergic or intolerant to clarithromycin, or in cases where resistance to clarithromycin is known or suspected 2.

From the Research

H. Pylori Treatment Options

• The standard triple therapy for H. pylori eradication is no longer effective as an empiric choice in most areas, even in low clarithromycin resistance areas 3.
• A 14-day regimen of high-dose proton pump inhibitor (PPI) triple therapy, consisting of lansoprazole, amoxicillin, and long-acting clarithromycin, has been shown to provide an excellent cure rate (100%) regardless of the CYP2C19 genotype 3.
• Another study compared the efficacy and tolerability of two first-line H. pylori eradication regimens: proton pump inhibitor-amoxicillin-clarithromycin and proton pump inhibitor-amoxicillin-metronidazole, and found that the latter was significantly more effective without differences in tolerability 4.

Factors Affecting Treatment Efficacy

• The choice of testing method for H. pylori infection should be based on several factors, including patient age, presenting symptoms, and medication use, as well as test reliability, availability, and cost 5.
• Rising antibiotic resistance, particularly of macrolides, requires careful selection of therapy based on regional resistance patterns and prior antibiotic exposure 5.
• The dosing schedule of amoxicillin has been shown to affect the eradication rate of H. pylori, with twice-daily dosing being as effective as four-times-daily dosing 6.
• The importance of clarithromycin dose in the management of H. pylori infection has been highlighted, with a meta-analysis showing that 500 mg b.d. is more effective than 250 mg b.d. in proton pump inhibitor-based triple therapies 7.

Treatment Strategies

• The "test-and-treat" strategy is the recommended approach for healthcare practitioners when managing H. pylori infection 5.
• Bismuth quadruple therapy should be considered as a first-line empiric treatment in areas with high macrolide resistance rates 5.
• Levofloxacin-based or alternative macrolide-containing therapies are also options for H. pylori eradication 5.
• It is essential to test for eradication after treatment, as untreated H. pylori is associated with serious complications, including peptic ulcer disease, mucosa-associated lymphoid tissue lymphoma, and gastric cancer 5.