What is the recommended treatment for a patient with confirmed Helicobacter pylori (H. pylori) infection and a history of dyspepsia or peptic ulcer disease?

H. pylori Treatment

For confirmed H. pylori infection with dyspepsia or peptic ulcer disease, use bismuth quadruple therapy for 14 days as first-line treatment, which includes a proton pump inhibitor, bismuth, tetracycline, and metronidazole. 1

First-Line Treatment Regimens

Bismuth quadruple therapy (BQT) for 14 days is the preferred empiric regimen when antibiotic susceptibility is unknown, due to increasing clarithromycin resistance rates in North America. 1 This regimen achieves eradication in the majority of treatment-naive patients and eliminates the risk of peptic ulcer recurrence. 2

Alternative first-line options include:

• Rifabutin triple therapy for 14 days (rifabutin + PPI + amoxicillin) in patients without penicillin allergy 1
• Concomitant therapy (non-bismuth quadruple therapy) consisting of PPI, clarithromycin, amoxicillin, and metronidazole for 14 days 1
• Triple therapy with PPI, clarithromycin, and amoxicillin for H. pylori infection and duodenal ulcer disease, though this is less preferred due to resistance concerns 3, 4

Treatment Duration and Dosing

All eradication regimens should be administered for a minimum of 14 days to maximize eradication rates. 1 The standard amoxicillin dosing for H. pylori eradication in adults is 1000 mg twice daily as part of triple therapy. 3

Proton pump inhibitors should be taken at the start of meals to minimize gastrointestinal intolerance. 3 Full-dose PPI therapy (e.g., omeprazole 20 mg once daily) is necessary for optimal symptom control and ulcer healing. 5

Post-Treatment Confirmation

Confirmation of H. pylori eradication is strongly recommended in all patients with peptic ulcer disease, particularly those with complicated ulcers, gastric ulcers, or duodenal ulcers. 6, 1

Testing should be performed no earlier than 4 weeks after treatment completion, and patients must discontinue antibiotics, bismuth, or PPIs at least 2 weeks before testing to avoid false-negative results. 6 The preferred confirmatory tests are:

• 13C-urea breath test (UBT) - highest accuracy 6, 4
• Stool antigen test - 90-95% accuracy 6

Serology is not appropriate for post-treatment confirmation as antibodies persist after eradication. 5

Salvage Therapy for Treatment Failure

For patients with persistent infection after initial therapy, "optimized" BQT for 14 days is preferred if they have not previously received optimized BQT. 1

Rifabutin triple therapy for 14 days is the preferred salvage regimen for patients who have failed optimized BQT. 1 Salvage regimens containing clarithromycin or levofloxacin should only be used if antibiotic susceptibility is confirmed. 1

Special Considerations

In NSAID users with H. pylori infection, eradication reduces peptic ulcer risk by 50% and should be pursued before initiating chronic NSAID therapy. 5, 7 However, eradication alone is insufficient in high-risk patients; co-administration of a PPI is strongly recommended. 5

For functional dyspepsia patients who are H. pylori positive, eradication provides long-term symptom relief in only 1 out of 12 patients. 6 However, eradication should still be pursued as preventive medicine, as H. pylori infection increases risk of future gastroduodenal disease including gastric cancer. 5

Management of Residual Symptoms

If dyspeptic symptoms persist after confirmed H. pylori eradication, treat based on predominant symptom pattern:

• For epigastric pain (ulcer-like dyspepsia): Full-dose PPI therapy (omeprazole 20 mg once daily) 5
• For fullness, bloating, or early satiety (dysmotility-like dyspepsia): Prokinetic agents, though cisapride is contraindicated due to cardiac toxicity 5

A trial of therapy withdrawal should be considered once symptoms are controlled, with on-demand therapy for recurrence. 5

Critical Pitfalls to Avoid

Do not use H2-receptor antagonists for gastroprotection in high-risk patients - they are inadequate compared to PPIs or misoprostol. 5

Do not rely on rapid office serological tests - their sensitivity and specificity (63-97% and 68-92% respectively) are too variable for reliable clinical use. 5

Do not assume symptom resolution equals eradication - objective confirmation is essential in peptic ulcer disease to prevent recurrence and complications. 6, 2