H. pylori Treatment Duration
The optimal duration for H. pylori eradication therapy is 14 days for all first-line regimens. 1
Evidence-Based Treatment Duration
14 days is the strongly recommended duration across all major international consensus guidelines (Toronto Consensus, Maastricht V/Florence, American College of Gastroenterology) to maximize first-attempt eradication success and avoid the complications of retreatment. 1
Why 14 Days?
Extending treatment from 7 to 14 days improves eradication success by approximately 5%, which translates to clinically meaningful differences in cure rates. 1, 2
The 14-day duration is superior to 10-day regimens, with studies showing 84.4% versus 78.5% eradication rates (14 vs 10 days), particularly for PPI-clarithromycin-amoxicillin triple therapy. 3
Longer duration compensates for increasing antibiotic resistance, especially clarithromycin resistance which now exceeds 15% in most regions. 1, 2
Duration by Regimen Type
Bismuth Quadruple Therapy
14 days is the preferred duration for bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline), achieving 80-90% eradication rates even with dual clarithromycin and metronidazole resistance. 1, 2, 4
10-14 days may be acceptable only if 10 days has been proven locally effective, but 14 days remains the default recommendation to ensure success on first attempt. 1
Concomitant Non-Bismuth Quadruple Therapy
- 14 days is mandatory for concomitant therapy (PPI + amoxicillin + clarithromycin + metronidazole) to maximize eradication in areas of high clarithromycin resistance. 1, 2
PPI Triple Therapy
14 days is required for all PPI triple therapy regimens (PPI + clarithromycin + amoxicillin or metronidazole), with clear evidence that 14 days outperforms 7 days (81.9% vs 72.9% eradication). 1, 3
For PPI-clarithromycin-amoxicillin specifically, the benefit of 14 versus 7 days is most pronounced (RR for persistence 0.65, NNT 12). 3
Levofloxacin Triple Therapy
- 14 days is recommended for levofloxacin-containing regimens (PPI + amoxicillin + levofloxacin) used as second-line therapy. 1, 2
Rifabutin Triple Therapy
- 10-14 days is acceptable for rifabutin-based rescue therapy (rifabutin + amoxicillin + PPI), with most guidelines recommending 14 days for consistency. 1, 2
Critical Optimization Beyond Duration
High-Dose PPI Twice Daily
High-dose PPI twice daily is mandatory, not optional—this increases cure rates by 6-12% compared to standard dosing by maintaining optimal gastric pH. 1, 2, 5
Esomeprazole or rabeprazole 40 mg twice daily may provide additional benefit over other PPIs. 2
PPIs must be taken 30 minutes before meals on an empty stomach without concomitant antacids. 2
Antibiotic Selection Based on Resistance
Avoid clarithromycin-containing regimens empirically in regions where clarithromycin resistance exceeds 15%, as eradication rates drop from 90% to 20% with resistant strains. 1, 2
Never repeat antibiotics previously used, especially clarithromycin and levofloxacin, where resistance develops rapidly after exposure. 1, 2
Common Pitfalls
Shorter Duration Regimens
Do not use 7-day regimens, even though older literature suggested they were adequate—current resistance patterns make them unacceptably ineffective. 1, 4
One-day treatment courses mentioned in older literature (2007) are no longer recommended and should be abandoned. 6
Inadequate Acid Suppression
- Standard-dose PPI once daily is inadequate—this is a major cause of treatment failure that is easily correctable. 2
Premature Test of Cure
Confirm eradication with urea breath test or stool antigen test at least 4 weeks after completion of therapy and at least 2 weeks after PPI discontinuation. 2, 5
Never use serology to confirm eradication, as antibodies persist long after successful treatment. 2
After Treatment Failure
After two failed eradication attempts, antibiotic susceptibility testing should guide further treatment whenever possible, as empiric therapy becomes increasingly unreliable. 2, 7, 8
Consider extending to 14 days for all rescue regimens, even if shorter durations are mentioned in older guidelines. 2, 7