Treatment of Erosive Gastritis with H. Pylori Infection
For erosive gastritis with confirmed H. pylori infection, bismuth quadruple therapy for 14 days is the recommended first-line treatment, consisting of a proton pump inhibitor (PPI) twice daily, bismuth subsalicylate, metronidazole, and tetracycline. 1
First-Line Eradication Regimen
The optimal approach prioritizes succeeding on the first treatment attempt to avoid retreatment, reduce costs, and minimize disruption to gut microbiota 2:
Bismuth Quadruple Therapy (14 days): 1, 2
- High-potency PPI (esomeprazole 20-40 mg OR rabeprazole 20 mg) twice daily
- Bismuth subsalicylate
- Metronidazole 500 mg twice daily
- Tetracycline
This regimen is preferred because it maintains effectiveness even with metronidazole-resistant strains and avoids clarithromycin, which faces increasing resistance rates 2.
Alternative if bismuth unavailable: Concomitant 4-drug therapy (PPI + amoxicillin + metronidazole + clarithromycin) for 14 days 1, 2
FDA-Approved Alternative Regimens
If bismuth quadruple therapy is not feasible, FDA-labeled alternatives include 3:
Triple Therapy:
- Amoxicillin 1 gram twice daily
- Clarithromycin 500 mg twice daily
- Lansoprazole 30 mg twice daily
- Duration: 14 days
Dual Therapy (for clarithromycin-allergic/intolerant patients):
- Amoxicillin 1 gram three times daily
- Lansoprazole 30 mg three times daily
- Duration: 14 days
Critical Treatment Principles
Duration matters: All guidelines converge on 14-day treatment duration for optimal eradication rates, as this significantly outperforms shorter courses 2, 1. The Toronto and Maastricht V/Florence consensus both emphasize that 14 days should be standard for all first-line therapies 2.
PPI potency affects outcomes: Higher-potency PPIs (rabeprazole, esomeprazole) improve H. pylori eradication rates compared to lower-potency options 1. Pantoprazole should be avoided when possible due to substantially lower potency (40 mg pantoprazole = only 9 mg omeprazole equivalent) 1.
Timing of administration: PPIs must be taken 30 minutes before meals to maximize effectiveness 1. Amoxicillin should be taken at the start of meals to minimize gastrointestinal intolerance 3.
Post-Treatment Confirmation
Mandatory eradication confirmation: After completing therapy, confirm successful H. pylori eradication using non-invasive testing (urea breath test or monoclonal stool antigen test) 1, 4. This should occur at least 4 weeks after completing antibiotics and 2 weeks after stopping PPI therapy 1.
Relying solely on symptom resolution without confirming eradication leads to persistent infection and complications 1.
Special Considerations for Erosive Gastritis
Gastric cancer risk stratification: Patients with erosive gastritis and H. pylori require assessment for atrophic changes, as the combination of H. pylori infection and atrophic gastritis significantly increases gastric cancer risk 2. Those with severe atrophy, corpus-predominant gastritis, or intestinal metaplasia need endoscopic surveillance every 3 years after eradication 2, 1.
Long-term PPI users: If the patient has been on long-term PPI therapy (>1 year), H. pylori eradication is particularly important as continued PPI use in H. pylori-positive patients accelerates progression to corpus-predominant and atrophic gastritis 1, 2.
NSAID co-exposure: If NSAIDs contributed to erosive gastritis, discontinue them if possible 1, 4. If NSAIDs must continue, maintain PPI therapy for gastroprotection even after H. pylori eradication 1.
Common Pitfalls to Avoid
- Inadequate PPI dosing or wrong timing: Taking PPIs at incorrect times relative to meals reduces acid suppression and eradication rates 1
- Using clarithromycin triple therapy without resistance data: Clarithromycin resistance exceeds 15% in most regions, making empiric triple therapy unreliable 2
- Stopping treatment early: The full 14-day course is essential; shorter durations have significantly lower eradication rates 2
- Not confirming eradication: Approximately 15-20% of patients fail first-line therapy and require retreatment with different antibiotics 2
If First-Line Therapy Fails
Choose second-line therapy based on what was used initially 2:
- If bismuth quadruple therapy failed: Use levofloxacin-based triple therapy
- If clarithromycin triple therapy failed: Use bismuth quadruple therapy
- Antibiotic susceptibility testing should guide retreatment when available 2
Renal Impairment Adjustments
For patients with severe renal impairment (GFR <30 mL/min), amoxicillin dosing requires adjustment 3:
- GFR 10-30 mL/min: 500 mg every 12 hours
- GFR <10 mL/min: 500 mg every 24 hours
- Hemodialysis: 500 mg every 24 hours with additional dose during and after dialysis