What is the recommended dosage and composition of a Helicobacter pylori (H. pylori) treatment kit for a patient with H. pylori infection gastritis?

H. Pylori Treatment Kit Composition and Dosing for Gastritis

Standard HP Kit Regimen (Bismuth Quadruple Therapy)

The recommended first-line treatment for H. pylori gastritis is bismuth quadruple therapy for 14 days, consisting of a high-dose proton pump inhibitor (PPI) twice daily, bismuth subsalicylate 262 mg (2 tablets) four times daily, metronidazole 500 mg three to four times daily (total 1.5-2 g daily), and tetracycline 500 mg four times daily. 1

Specific Component Dosing

PPI Component:

• Esomeprazole 40 mg twice daily or rabeprazole 20 mg twice daily are strongly preferred, as they increase cure rates by 8-12% compared to other PPIs 1, 2, 3
• Alternative: Lansoprazole 30 mg twice daily 3
• Avoid pantoprazole due to significantly lower potency (40 mg pantoprazole = only 9 mg omeprazole equivalents) 1, 3
• Timing is critical: Take 30 minutes before meals on an empty stomach, without concomitant antacids 1, 2

Bismuth Component:

• Bismuth subsalicylate 262 mg (2 tablets) four times daily 1
• Alternative: Bismuth subcitrate 120 mg four times daily 1

Antibiotic Components:

• Metronidazole 500 mg three to four times daily (total daily dose 1.5-2 g) 1
• Tetracycline 500 mg four times daily 1

Treatment Duration:

• 14 days is mandatory—this improves eradication by approximately 5% compared to 7-10 day regimens 1, 2

Why This Regimen Works

• Achieves 80-90% eradication rates even against strains with dual resistance to clarithromycin and metronidazole 1
• No bacterial resistance to bismuth has been described 1
• Bismuth's synergistic effect overcomes metronidazole resistance in vitro 1
• Uses "Access group" antibiotics (tetracycline, metronidazole) rather than "Watch group" antibiotics (clarithromycin, levofloxacin), supporting antimicrobial stewardship 1, 2

Alternative First-Line Option (When Bismuth Unavailable)

Concomitant non-bismuth quadruple therapy for 14 days: 1, 3

• High-dose PPI (esomeprazole 40 mg or rabeprazole 20 mg) twice daily
• Amoxicillin 1000 mg twice daily 1, 4
• Clarithromycin 500 mg twice daily 1
• Metronidazole 500 mg twice daily 1

Critical caveat: Only use this regimen in areas with documented clarithromycin resistance below 15%, which is now rare in most of North America and Europe 1

Administration Instructions

Meal Timing:

• PPI: 30 minutes before meals 1, 2
• Amoxicillin (if used): At the start of a meal to minimize gastrointestinal intolerance 4
• Other antibiotics: Can be taken with or without food 1

Storage:

• If using amoxicillin suspension: Shake well before use, refrigeration preferable but not required, discard after 14 days 4

Second-Line Treatment (After First-Line Failure)

If bismuth quadruple therapy fails, use levofloxacin triple therapy (provided no prior fluoroquinolone exposure): 1

• High-dose PPI (esomeprazole 40 mg or rabeprazole 20 mg) twice daily
• Amoxicillin 1000 mg twice daily
• Levofloxacin 500 mg once daily (or 250 mg twice daily)
• Duration: 14 days

Critical pitfall: Never repeat antibiotics that failed previously, especially clarithromycin and levofloxacin, where resistance develops rapidly after exposure 1

Confirmation of Eradication

• Test at least 4 weeks after completing therapy using urea breath test or monoclonal stool antigen test 1, 2
• Discontinue PPI at least 2 weeks before testing to avoid false-negative results 1, 2
• Never use serology to confirm eradication—antibodies persist long after successful treatment 1

Common Pitfalls to Avoid

• Inadequate PPI dosing: Standard once-daily dosing is inadequate—always use twice-daily high-dose PPI 1, 2
• Wrong PPI timing: Must be taken 30 minutes before meals for optimal activation 1, 2
• Treatment duration less than 14 days: Reduces eradication rates by approximately 5% 1, 2
• Failure to test for H. pylori eradication: Relying on symptom resolution alone allows persistent infection 2, 3
• Prescribing long-term PPIs without first eradicating H. pylori: Accelerates progression to corpus-predominant atrophic gastritis 2, 3

Special Populations

Penicillin allergy:

• Bismuth quadruple therapy is the first choice (contains tetracycline, not amoxicillin) 1
• Consider penicillin allergy testing to enable amoxicillin use, as most reported allergies are not true allergies 1

Renal impairment (GFR <30 mL/min):

• Amoxicillin dosing adjustment required: 500 mg or 250 mg every 12 hours (GFR 10-30 mL/min) or every 24 hours (GFR <10 mL/min) 4