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

From the Guidelines

The recommended first-line treatment for H. pylori infection is a 14-day quadruple therapy regimen consisting of a proton pump inhibitor (PPI) such as omeprazole 20mg twice daily, bismuth subsalicylate 524mg four times daily, tetracycline 500mg four times daily, and metronidazole 500mg three times daily. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of succeeding on the first attempt to avoid retreating and retesting, and reducing cost, anxiety, and negative impacts on other gut microbiota 1.

Key Considerations

• The choice of first-line treatment should be guided by previous antibiotic exposure or known local prevalence of resistant organisms 1.
• Bismuth quadruple therapy is favored in areas of high dual resistance to clarithromycin and metronidazole, and concomitant therapy is appropriate for those patients from areas of high clarithromycin resistance where bismuth is not available 1.
• The duration of first-line therapies should be 14 days, as there is sufficient evidence of higher success with 14 days vs shorter durations 1.

Treatment Regimens

• A 14-day triple therapy can be used with a PPI, amoxicillin 1g twice daily, and clarithromycin 500mg twice daily, though this has lower eradication rates due to increasing antibiotic resistance 1.
• For patients allergic to penicillin, metronidazole can replace amoxicillin 1.
• Treatment success should be confirmed with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and at least 2 weeks after stopping PPI therapy 1.

Importance of H. pylori Eradication

• H. pylori eradication is important because the bacterium causes chronic gastritis and is associated with peptic ulcer disease, gastric cancer, and MALT lymphoma 1.
• If first-line therapy fails, subsequent treatment should be guided by antibiotic susceptibility testing when available, using different antibiotics than in the initial regimen 1.

Refractory H. pylori Infection

• The usual cause of refractory H. pylori infection is antibiotic resistance, and providers should attempt to identify other contributing etiologies, including inadequate adherence to therapy and insufficient gastric acid suppression 1.
• Eradication regimens for H. pylori are complex and might not be fully comprehended by patients, and barriers to adherence should be explored and addressed prior to prescribing therapy 1.

From the FDA Drug Label

Adult Patients only Helicobacter pylori Infection and Duodenal Ulcer Disease: Triple therapy for Helicobacter pylori (H. pylori) with clarithromycin and lansoprazole : Amoxicillin, in combination with clarithromycin plus lansoprazole as triple therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) to eradicate H. pylori. Dual therapy for H. pylori with lansoprazole : Amoxicillin, in combination with lansoprazole delayed-release capsules as dual therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) who are either allergic or intolerant to clarithromycin or in whom resistance to clarithromycin is known or suspected.

H. Pylori Treatment: Amoxicillin is indicated for the treatment of H. pylori infection in combination with other medications.

• Triple Therapy: Amoxicillin can be used in combination with clarithromycin and lansoprazole to treat H. pylori infection and duodenal ulcer disease.
• Dual Therapy: Amoxicillin can also be used in combination with lansoprazole as dual therapy for patients who are allergic or intolerant to clarithromycin or have known or suspected resistance to clarithromycin 2.

From the Research

H. Pylori Treatment Options

• The treatment of H. pylori infection typically involves a combination of antibiotics and a proton pump inhibitor (PPI) 3, 4, 5.
• Two commonly used first-line therapies for H. pylori infection are proton-pump inhibitor and amoxicillin-based triple therapy, including clarithromycin (PAC) and metronidazole (PAM) 3.
• The efficacy of PAC and PAM regimens has been compared in several studies, with results showing that both regimens are effective and comparable in eradicating H. pylori 3.
• However, the PAM regimen has been shown to be more effective in recent years, especially for people over 60 years old 3.
• Bismuth quadruple therapy is also recommended as a first-line treatment, especially in areas with high resistance rates to clarithromycin 4, 5.

Antibiotic Resistance and Treatment

• Antibiotic resistance, particularly to macrolides, is a growing concern in the treatment of H. pylori infection 4, 5.
• The choice of treatment should be based on regional resistance patterns and prior antibiotic exposure 5.
• Susceptibility-guided treatment appears to be the ideal approach, but the feasibility and cost-effectiveness of universal pre-treatment susceptibility testing need to be evaluated 4.
• Molecular testing methods may provide a convenient way to characterize H. pylori antibiotic susceptibility 4.

Treatment Regimens and Efficacy

• A study comparing omeprazole, clarithromycin, and amoxicillin therapy with colloidal bismuth subcitrate, amoxicillin, and metronidazole therapy found that the former regimen had a higher eradication rate (89.6% vs 71.7%) 6.
• A meta-analysis of triple therapies with a proton pump inhibitor, clarithromycin, and amoxycillin or metronidazole found that clarithromycin 500 mg b.d. was more effective than 250 mg b.d. in eradicating H. pylori 7.
• The importance of clarithromycin dose in the management of H. pylori infection has been highlighted, with higher doses (500 mg b.d.) being more effective than lower doses (250 mg b.d.) 7.