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

Treatment of Helicobacter pylori Infection

For treatment-naive patients with H. pylori infection, bismuth quadruple therapy (BQT) for 14 days is the preferred first-line regimen when antibiotic susceptibility is unknown. 1

First-Line Treatment Regimens

The choice of initial therapy depends critically on local clarithromycin resistance patterns:

In Areas with High Clarithromycin Resistance (≥15%)

• 14-day bismuth quadruple therapy (BQT) is strongly recommended 2
• 14-day concomitant therapy (non-bismuth quadruple therapy with PPI + amoxicillin + clarithromycin + metronidazole) is an alternative 2, 1
• These regimens achieve eradication rates exceeding 80% on intention-to-treat analysis 3

In Areas with Low Clarithromycin Resistance (<15%)

• 14-day triple therapy (PPI + clarithromycin + amoxicillin) is acceptable 2
• 14-day BQT remains an effective option 2

Alternative First-Line Options

• Rifabutin triple therapy for 14 days is suitable for patients without penicillin allergy 1
• Potassium-competitive acid blocker (P-CAB) dual therapy for 14 days (vonoprazan-based) is emerging as an effective alternative 1

Second-Line Treatment (After First-Line Failure)

If BQT was not used initially, 14-day optimized BQT is the preferred second-line regimen. 1

• 14-day levofloxacin triple therapy (PPI + levofloxacin + amoxicillin) is an alternative if BQT was already used 2, 1
• Salvage regimens containing clarithromycin or levofloxacin should only be used if antibiotic susceptibility is confirmed 1

Third-Line and Salvage Therapy

For patients with multiple treatment failures, antimicrobial susceptibility testing (AST) should be performed to guide therapy. 2

When AST is unavailable:

• Use antibiotics not previously administered or for which resistance is unlikely 2
• Consider: amoxicillin, tetracycline, bismuth, furazolidone, or rifabutin 4, 2
• High-dose PPI/amoxicillin therapy may be promising 4

Key Treatment Principles

Acid Suppression

• High-dose potent proton pump inhibitor or vonoprazan is recommended to achieve adequate acid suppression 2
• Amoxicillin should be taken at the start of meals to minimize gastrointestinal intolerance 5

Treatment Duration

• 14-day regimens are superior to 7-day regimens for all treatment protocols 3, 2
• Treatment should continue for minimum 48-72 hours beyond symptom resolution 5

Adjuvant Therapy

• Probiotics can reduce antibiotic side effects and enhance eradication rates when used as adjuvant treatment 2

Post-Treatment Confirmation

Universal test-of-cure is strongly recommended in all treated patients, particularly those with complicated peptic ulcer disease, gastric ulcer, or gastric MALT lymphoma. 6

• Testing should occur no earlier than 4 weeks after treatment cessation 6
• Stop antibiotics, bismuth, or PPIs at least 2 weeks before testing to avoid false-negative results 3, 6
• Preferred tests: 13C-urea breath test or monoclonal stool antigen test 6

Common Pitfalls to Avoid

• Do not use clarithromycin-based triple therapy in areas with ≥15% resistance - this leads to unacceptably high failure rates 2
• Avoid 7-day treatment regimens - they are inferior to 14-day courses 3
• Do not test too early after treatment - wait at least 4 weeks to prevent false-negative results 6
• Do not ignore antibiotic resistance patterns - local surveillance data should guide empiric therapy selection 3

Clinical Benefits of Eradication

Beyond treating active symptoms, H. pylori eradication provides multiple benefits:

• Prevents peptic ulcer recurrence in over 90% of patients with documented ulcer disease 3
• Cures low-grade gastric MALT lymphoma in 60-80% of early-stage cases 3
• Provides long-term dyspepsia relief with a number needed to treat of 12 in functional dyspepsia 3, 6
• Heals gastritis and prevents progression to atrophic gastritis in patients on long-term PPIs 3
• Reduces gastric cancer risk by halting the progression of precancerous lesions 3
• Prevents NSAID-associated ulcers when eradicated before starting NSAID therapy 3
• Improves bioavailability of thyroxine and L-dopa 3
• Treats associated conditions including iron-deficiency anemia, idiopathic thrombocytopenic purpura, and vitamin B12 deficiency 3