H. pylori Treatment
Bismuth quadruple therapy (BQT) for 14 days is the preferred first-line treatment for confirmed H. pylori infection, consisting of a proton pump inhibitor (PPI) twice daily, bismuth (~300mg four times daily), metronidazole (500mg three times daily), and tetracycline (500mg four times daily). 1, 2, 3
First-Line Treatment Regimen
Bismuth quadruple therapy is the gold standard empiric first-line regimen because it avoids clarithromycin entirely and maintains 80-90% eradication rates despite rising antibiotic resistance patterns, which is the most important factor responsible for treatment failure. 1, 3, 4
Standard BQT Components:
- PPI twice daily (pantoprazole 40mg, lansoprazole 30mg, omeprazole 20mg, esomeprazole 20mg, or rabeprazole 20mg) 3
- Bismuth subsalicylate ~300mg four times daily 1, 3
- Metronidazole 500mg three times daily 1
- Tetracycline 500mg four times daily 1
- Duration: 14 days mandatory 1, 2, 3
Alternative First-Line Option (Penicillin Allergy):
If the patient has a penicillin allergy, BQT remains the preferred regimen as it does not contain penicillin-class antibiotics. 2
Alternative First-Line Option (Low Clarithromycin Resistance Areas):
In documented low clarithromycin resistance areas (<15%), PPI-clarithromycin-amoxicillin triple therapy for 14 days can be used, though BQT is still preferred. 2, 5
Critical Treatment Optimization Factors
High-dose PPI twice daily is mandatory and increases eradication success by approximately 5-10% compared to standard once-daily dosing. 1, 3 This is non-negotiable for optimal outcomes.
The 14-day treatment duration is superior to 7-10 day regimens by approximately 5%, and shorter durations should never be used. 1, 2, 3
Patient adherence is crucial—incomplete treatment leads to antibiotic resistance and treatment failure, so ensure patients understand the importance of completing the full 14-day course. 1, 2
Second-Line Treatment (After First-Line Failure)
If BQT was not used as first-line therapy, optimized BQT for 14 days is the preferred second-line regimen. 1, 2, 4
Levofloxacin-containing triple therapy for 14 days (PPI twice daily, amoxicillin, and levofloxacin) is an alternative second-line option, though rising fluoroquinolone resistance rates must be considered. 1, 3
Rifabutin triple therapy for 14 days is highly effective as rescue therapy after multiple treatment failures, consisting of rifabutin, amoxicillin, and PPI twice daily. 3, 4
Confirmation of Eradication
All patients must undergo test-of-cure at least 4 weeks after completing treatment using urea breath test or laboratory-based validated monoclonal stool antigen test. 2, 4
PPIs must be discontinued at least 2 weeks before testing to avoid false-negative results due to bacterial suppression. 1, 2
Key Clinical Pitfalls to Avoid
Never perform H. pylori testing while a patient is taking PPIs, antibiotics, or bismuth within the specified washout periods (at least 2 weeks for PPIs), as bacterial suppression will yield false-negative results. 1, 2
Antibiotic resistance is the most important factor responsible for eradication failure—local surveillance of resistance patterns is mandatory for optimal treatment selection. 1, 2, 5
Never assume low clarithromycin resistance without local surveillance data, and avoid repeating clarithromycin if the patient has prior macrolide exposure for any indication. 3
Do not reduce bismuth dosing below the standard ~300mg four times daily, as dose reduction represents a 42% reduction that is not supported by any guideline or evidence and will compromise eradication rates. 3
Special Populations
In children under 8 years, tetracycline should not be used due to risk of permanent tooth discoloration and impaired bone growth. 1
Fluoroquinolones should be avoided in children due to risk of cartilage damage and tendon rupture. 1
Clinical Context and Indications for Treatment
All patients with confirmed H. pylori infection should be offered eradication therapy, particularly those with active or past peptic ulcer disease, as eradication reduces ulcer recurrence risk by >90%. 1, 5
Patients under 45-55 years without alarm symptoms should be tested for H. pylori non-invasively and treated if positive using the "test and treat" strategy. 1
Managing Expectations After Treatment
Many patients will have residual dyspeptic symptoms after successful H. pylori eradication, particularly those with functional dyspepsia. 1 The primary benefit of eradication is elimination of peptic ulcer mortality risk and prevention of gastric cancer, not necessarily symptom resolution. 1 Residual symptoms should be managed with empirical acid suppression therapy (PPIs) if epigastric pain predominates. 1