Should I start Helicobacter pylori (H. pylori) treatment?

Should You Start H. pylori Treatment?

Yes, you should start H. pylori eradication therapy if you have confirmed H. pylori infection, particularly if you have peptic ulcer disease, gastric MALT lymphoma, gastritis, or are at risk for gastric cancer. 1, 2

When H. pylori Treatment is Strongly Indicated

H. pylori eradication must be given to all patients with gastric MALT lymphoma, independently of stage, as antibiotic therapy alone can induce lymphoma regression and long-term disease control in most patients. 1

Additional strong indications for treatment include:

• Active or past history of peptic ulcer disease (gastric or duodenal ulcer), where eradication reduces recurrence risk and prevents complications 1, 3
• Precancerous gastric lesions or atrophic gastritis, as H. pylori is the most consistent risk factor for gastric cancer and eradication is the most promising prevention strategy 1
• Family history of gastric cancer, where early eradication before preneoplastic lesions develop can prevent cancer 1
• Chronic NSAID or aspirin use, to reduce ulcer risk 3
• Iron deficiency anemia, idiopathic thrombocytopenic purpura, or vitamin B12 deficiency 3

Recommended First-Line Treatment Regimen

Bismuth quadruple therapy for 14 days is the preferred first-line treatment in most clinical scenarios, particularly in areas with high clarithromycin resistance (≥15%), which now includes most of North America and Europe. 2, 4, 5

The regimen consists of:

• Proton pump inhibitor (PPI) twice daily (preferably high-potency: esomeprazole or rabeprazole 40 mg twice daily, taken 30 minutes before meals) 2, 4
• Bismuth subsalicylate 262 mg or bismuth subcitrate 120 mg four times daily 2, 5
• Metronidazole 500 mg three to four times daily (total 1.5-2 g/day) 2, 5
• Tetracycline 500 mg four times daily 2, 5

This regimen achieves 80-90% eradication rates even against metronidazole-resistant strains because bismuth's synergistic effect overcomes resistance, and bacterial resistance to bismuth is extremely rare. 2, 4

Alternative First-Line Option When Bismuth is Unavailable

Concomitant non-bismuth quadruple therapy for 14 days is the recommended alternative: 2, 4

• PPI twice daily 2
• Amoxicillin 1000 mg twice daily 2, 6
• Clarithromycin 500 mg twice daily 2
• Metronidazole 500 mg twice daily 2

This regimen administers all antibiotics simultaneously, preventing resistance development during treatment. 2

Critical Factors for Treatment Success

The 14-day treatment duration is mandatory—extending from 7 to 14 days improves eradication success by approximately 5%. 2, 4, 5

High-dose PPI twice daily is non-negotiable, as it increases efficacy by 6-12% compared to standard dosing by reducing gastric acidity and enhancing antibiotic activity. 2, 4

Never use standard triple therapy (PPI + clarithromycin + amoxicillin) empirically in areas where clarithromycin resistance exceeds 15-20%, as eradication rates drop from 90% with susceptible strains to only 20% with resistant strains. 1, 2, 4

Special Considerations for MALT Lymphoma

In H. pylori-positive gastric MALT lymphoma, antibiotic eradication therapy should be the sole initial treatment, regardless of stage. 1

• Wait at least 12 months before starting oncological treatment in patients who achieve clinical and endoscopic remission with H. pylori eradication, even if microscopic lymphoma persists on histology 1
• In H. pylori-negative MALT lymphoma cases, a trial of anti-Helicobacter therapy may still be worthwhile (possibly due to false-negative testing or other Helicobacter species), but if no regression occurs at 3-6 months, proceed to radiotherapy or systemic treatment 1

Confirming Eradication

Test for eradication success at least 4 weeks after completing therapy using urea breath test or monoclonal stool antigen test, and discontinue PPI at least 2 weeks before testing. 2, 4, 5

Never use serology to confirm eradication—antibodies persist long after successful treatment. 2, 4

Common Pitfalls to Avoid

• Do not use once-daily PPI dosing—always prescribe twice daily 2, 4
• Do not repeat antibiotics the patient has previously been exposed to, especially clarithromycin or levofloxacin, as resistance develops rapidly 2, 4
• Do not assume low clarithromycin resistance without local surveillance data—most regions now have high resistance rates 2
• Do not use 7-day regimens—14 days is superior 2, 4, 5

Second-Line Treatment After First Failure

If bismuth quadruple therapy was not used first-line, use it as second-line for 14 days. 2, 4

Alternatively, levofloxacin-based triple therapy (PPI twice daily + amoxicillin 1000 mg twice daily + levofloxacin 500 mg once daily or 250 mg twice daily) for 14 days can be used in areas with low levofloxacin resistance. 2, 4, 5

After two failed eradication attempts, antibiotic susceptibility testing should guide further treatment whenever possible. 2, 4, 5