From the Guidelines
The most effective treatment for H. pylori infection is a 14-day bismuth quadruple therapy, which includes a proton pump inhibitor (PPI), bismuth subsalicylate, tetracycline, and metronidazole, as it avoids the potential problem of antibiotic overuse and has acceptable success even in strains displaying in vitro metronidazole resistance. This approach is recommended by recent guidelines, including the Toronto Consensus and the Maastricht V/Florence Consensus, as it provides the best chance of success on the first attempt, reducing the need for retreatment and retesting, and minimizing the negative impacts on other gut microbiota 1.
Key Components of Treatment
- A PPI, such as omeprazole, to reduce stomach acid
- Bismuth subsalicylate, which has antimicrobial properties
- Tetracycline, an antibiotic that targets H. pylori
- Metronidazole, an antibiotic that is effective against H. pylori, even in cases of metronidazole resistance
Duration and Administration
The recommended duration of first-line therapies is 14 days, as this has been shown to have higher success rates compared to shorter durations 1. Patients should take their medications with food to reduce gastrointestinal side effects and complete the full course of antibiotics, even if symptoms improve.
Considerations and Alternatives
For patients from areas with high dual resistance to clarithromycin and metronidazole, bismuth quadruple therapy is particularly encouraged 1. In cases where bismuth is not available, concomitant therapy or levofloxacin-based triple therapy may be considered, although the latter is not generally recommended as a first-line option due to concerns about antibiotic resistance 1.
Follow-Up and Monitoring
Confirmation of eradication should be performed at least 4 weeks after completing therapy using either a urea breath test, stool antigen test, or endoscopic biopsy. This is crucial to ensure that the treatment has been effective and to reduce the risk of complications, such as peptic ulcers and gastric cancer, which are associated with H. pylori infection.
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 with amoxicillin can be done through two regimens:
- Triple therapy with clarithromycin and lansoprazole
- Dual therapy with lansoprazole, for patients who are allergic or intolerant to clarithromycin, or in cases of known or suspected resistance to clarithromycin 2
From the Research
H.pylori Treatment Options
- The "test-and-treat" strategy is the recommended approach for healthcare practitioners when managing H. pylori infection 3.
- The choice of testing method should be based on several factors including patient age, presenting symptoms, and medication use, as well as test reliability, availability, and cost 3.
- With rising antibiotic resistance, particularly of macrolides, care must be taken to ensure that therapy is selected based on regional resistance patterns and prior antibiotic exposure 3.
First-Line Treatment
- Triple therapy including a proton pump inhibitor, clarithromycin, and amoxicillin (PPI-CA) is the first-choice treatment used for H. pylori eradication 4.
- However, the efficacy of this treatment is declining, and alternative therapies are currently under evaluation 4.
- Triple therapy with a PPI, amoxicillin, and levofloxacin (PPI-LA) has been shown to have low efficiency, less than 80%, and is not recommended as a first-choice treatment for H. pylori eradication 4.
Second-Line Treatment
- A standard bismuth quadruple therapy, a fluoroquinolone-containing triple (or quadruple) therapy, or a proton pump inhibitor (PPI)-amoxicillin high-dose dual therapy has been recommended as a second-line treatment for Helicobacter pylori infection 5.
- Ten-day PPI-bismuth-tetracycline-levofloxacin quadruple therapy is a good option for rescue treatment of H. pylori infection following failure of standard triple or non-bismuth quadruple therapy 6.
- High-dose dual PPI-amoxicillin therapy is another novel second-line treatment for H. pylori infection, achieving an eradication rate of 89% by per-protocol analysis 5.
- Levofloxacin-based sequential quadruple therapy and potassium-competitive acid blocker have also been applied in the second-line treatment of H. pylori infection 5.
Comparison of Treatment Regimens
- A randomized controlled trial compared the efficacy of esomeprazole-bismuth-tetracycline-levofloxacin therapy (TL quadruple therapy) and esomeprazole-amoxicillin-levofloxacin triple therapy (AL triple therapy) in rescue treatment for H. pylori infection, showing that TL quadruple therapy achieved a markedly higher eradication rate than AL triple therapy 6.
- Another study compared the safety and efficacy of a new quadruple therapy regimen (azithromycin, ofloxacin, bismuth, and omeprazole) with the standard second-line treatment (amoxicillin, clarithromycin, bismuth, and omeprazole) for H. pylori eradication, showing that the new regimen was effective and safe 7.