From the Guidelines
The most effective treatment for H pylori infection is a 14-day course of bismuth quadruple therapy, which includes a proton pump inhibitor, bismuth subsalicylate, tetracycline, and metronidazole, as it avoids the potential problem of antibiotic overuse and has acceptable success even in strains displaying in vitro metronidazole resistance. This approach is recommended by recent guidelines, including the Toronto Consensus and the Maastricht V/Florence Consensus, as it provides the best chance of success on the first attempt, reducing the need for retreatment and retesting, and minimizing the negative impacts on other gut microbiota 1.
When choosing a first-line treatment, it is essential to consider the local prevalence of resistant organisms and previous antibiotic exposure. The guidelines suggest selecting one of three regimens based on these factors, with bismuth quadruple therapy being a preferred option in areas with high dual resistance to clarithromycin and metronidazole. Some key points to consider when treating H pylori infection include:
- The importance of avoiding antibiotics and PPIs for at least 2 weeks before testing to prevent false negative results
- The need for confirmation of eradication at least 4 weeks after completing therapy using a urea breath test, stool antigen test, or endoscopic biopsy
- The increasing global problem of antibiotic resistance, particularly for clarithromycin, which can affect treatment success rates
- The potential consequences of untreated H pylori infection, including chronic gastritis, peptic ulcers, gastric cancer, and MALT lymphoma.
In terms of specific treatment regimens, the guidelines recommend the following:
- Bismuth quadruple therapy for 14 days, which includes a proton pump inhibitor, bismuth subsalicylate 525mg four times daily, tetracycline 500mg four times daily, and metronidazole 250mg four times daily
- Concomitant therapy, which includes a proton pump inhibitor, amoxicillin, and clarithromycin, for patients from areas with high clarithromycin resistance where bismuth is not available. Overall, the goal of treatment is to achieve eradication of H pylori, reducing the risk of associated diseases and improving patient outcomes, as supported by recent evidence 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 options with amoxicillin include:
- Triple therapy: amoxicillin, clarithromycin, and lansoprazole
- Dual therapy: amoxicillin and lansoprazole, for patients who are allergic or intolerant to clarithromycin, or in cases of known or suspected clarithromycin resistance 2
From the Research
H pylori Treatment Options
- First-line treatment options include concomitant nonbismuth quadruple therapy (proton pump inhibitor + amoxicillin + metronidazole + clarithromycin) and traditional bismuth quadruple therapy (proton pump inhibitor + bismuth + metronidazole + tetracycline) 3
- Quadruple therapies, such as bismuth quadruple and concomitant nonbismuth quadruple therapies, are recommended as first-line regimens in areas with high clarithromycin resistance 4
- The choice of H. pylori eradication regimen should be based on the local prevalence of clarithromycin resistance and the previous use of macrolides 5
Treatment Duration and Efficacy
- All H. pylori eradication regimens should be given for 14 days 3
- The efficacy of sequential therapy against clarithromycin-resistant H. pylori strains is contradictory, and its use is generally discouraged 5
- Second-line treatments include levofloxacin-containing triple therapy and bismuth quadruple therapy 5
Alternative Treatment Options
- A novel potassium-competitive acid blocker-based eradication regimen could be a valuable eradication option in the near future 4
- High-dose dual therapy (proton-pump-inhibitor plus amoxicillin) and vonoprazan, a more potent acid inhibitor, are promising alternatives that could decrease misuse of antibiotics 6
- Addition of certain probiotics could somewhat increase the performance of H. pylori eradication regimens, while improving tolerability 6