Treatment for 17-Year-Old with Positive Urea Breath Test
Bismuth quadruple therapy for 14 days is the definitive first-line treatment for this adolescent with confirmed H. pylori infection, consisting of high-dose PPI twice daily, bismuth subsalicylate, metronidazole, and tetracycline. 1, 2
First-Line Treatment Regimen
The American College of Gastroenterology recommends the following specific regimen for adolescents 1:
- High-dose PPI (esomeprazole or rabeprazole 40 mg) twice daily, taken 30 minutes before meals on an empty stomach 1, 2
- Bismuth subsalicylate 262 mg (2 tablets) four times daily 1, 2
- Metronidazole 500 mg three to four times daily (total 1.5-2 g daily) 1, 2
- Tetracycline 500 mg four times daily 1, 2
- Duration: 14 days mandatory (not shorter) 1, 2
This regimen achieves 80-90% eradication rates even in areas with high clarithromycin and metronidazole resistance, with no bacterial resistance to bismuth described and rare tetracycline resistance (<5%). 1, 2
Critical Optimization Factors
Treatment duration of 14 days is mandatory, improving eradication success by approximately 5% compared to 7-10 day regimens. 1, 2 High-dose PPI twice daily increases cure rates by an additional 8-12% compared to standard PPIs. 1, 2
Medications should be taken at the start of meals to maximize absorption and minimize gastrointestinal side effects, except PPIs which must be taken 30 minutes before meals on an empty stomach, without concomitant use of other antacids. 1, 3
Alternative First-Line Option (If Bismuth Unavailable)
The European Society of Gastrointestinal Endoscopy recommends concomitant non-bismuth quadruple therapy for 14 days as an alternative when bismuth is unavailable 1, 2:
- PPI twice daily
- Amoxicillin 1000 mg twice daily
- Clarithromycin 500 mg twice daily
- Metronidazole 500 mg twice daily
However, this should only be used if bismuth quadruple therapy is truly unavailable, as bismuth-based therapy is superior in areas with clarithromycin resistance. 1, 2
Confirmation of Eradication
The urea breath test or validated monoclonal stool antigen test should be used to confirm eradication success at least 4 weeks after completing therapy, with PPIs discontinued at least 2 weeks before testing to avoid false-negative results. 1, 2 The urea breath test has sensitivity and specificity of 94.7% and 95.7% respectively. 4
Serology should never be used to confirm eradication, as antibodies persist long after successful treatment and cannot distinguish active from past infection. 1, 2
Patient Factors That Affect Success
Smoking increases the risk of eradication failure with an odds ratio of 1.95. 1 High BMI increases failure risk due to lower drug concentrations at the gastric mucosal level. 1 Poor compliance is a major cause of treatment failure—counsel the patient on the importance of completing the full 14-day course despite potential side effects. 5
Diarrhea occurs in 21-41% of patients during the first week due to disruption of normal gut microbiota. 2 Consider adjunctive probiotics to reduce the risk of diarrhea and improve patient compliance, though evidence for increasing eradication rates is limited. 2
Second-Line Treatment (If First-Line Fails)
After first-line bismuth quadruple therapy failure, levofloxacin triple therapy for 14 days can be used if there is no prior fluoroquinolone exposure 1, 2:
- PPI twice daily
- Amoxicillin 1000 mg twice daily
- Levofloxacin 500 mg once daily
Common Pitfalls to Avoid
- Never use 7-10 day regimens—14 days is mandatory for optimal eradication 1, 2
- Never use standard-dose PPI once daily—high-dose twice-daily dosing is required 1, 2
- Never repeat antibiotics that failed previously, especially clarithromycin and levofloxacin where resistance develops rapidly after exposure 1, 2
- Never test for eradication before 4 weeks post-treatment or while on PPIs (must stop 2 weeks before testing) 1, 2