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, and two antibiotics, as it has the highest success rate and avoids the potential problem of antibiotic overuse. This approach is recommended by recent guidelines, including the Toronto Consensus and the Maastricht V/Florence Consensus, as it provides the best chance of eradicating the infection on the first attempt, thus reducing the need for retreatment and minimizing the risk of antibiotic resistance 1. The use of bismuth quadruple therapy is particularly encouraged in areas with high dual resistance to clarithromycin and metronidazole.
Some key points to consider when treating H pylori infection include:
- The importance of choosing a treatment regimen based on previous antibiotic exposure or local prevalence of resistant organisms
- The need to avoid antibiotic overuse and minimize the risk of resistance
- The use of concomitant therapy as an alternative to bismuth quadruple therapy in areas with high clarithromycin resistance where bismuth is not available
- The recommendation for a 14-day treatment duration, as it has been shown to have a higher success rate than shorter durations 1
It is also important to note that levofloxacin is not considered a first-line therapy for most patients, but may be considered in certain cases where bismuth is not available and the patient is from an area with high dual resistance and low levofloxacin resistance 1. After completing treatment, patients should undergo testing to confirm eradication, typically using a urea breath test or stool antigen test at least 4 weeks after therapy and after stopping PPI for 2 weeks.
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 [PPI] + amoxicillin + metronidazole + clarithromycin [PAMC]) and traditional bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline [PBMT]) 3
- PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole) is restricted to areas with known low clarithromycin resistance or high eradication success with these regimens 3
- Recommended rescue therapies include PBMT and levofloxacin-containing therapy (PPI + amoxicillin + levofloxacin) 3
Treatment Duration and Antibiotic Resistance
- All H pylori eradication regimens should be given for 14 days due to increasing failure of therapy 3
- Increasing antibiotic resistance of H pylori is a significant factor contributing to eradication failure, and selecting the most appropriate regimen depending on resistance is optimal 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
Diagnostic and Management Strategies
- The "test-and-treat" strategy is the recommended approach for healthcare practitioners when managing H pylori infection 6
- The choice of testing method should be based on several factors including patient age, presenting symptoms, and medication use, as well as test reliability, availability, and cost 6
- Once treated, it is essential to test for eradication as untreated H pylori is associated with serious complications including peptic ulcer disease, mucosa-associated lymphoid tissue lymphoma, and gastric cancer 6