What is the current recommended treatment for a patient with H. pylori gastritis?

Current Management of H. pylori Gastritis

Eradicate H. pylori infection in all diagnosed cases of H. pylori gastritis using bismuth-containing quadruple therapy for 14 days as first-line treatment, as this prevents progression to atrophic gastritis, reduces gastric cancer risk, and achieves eradication rates exceeding 80%. 1

First-Line Treatment Regimen

The preferred empirical first-line therapy consists of bismuth-containing quadruple therapy for 14 days 1:

• Bismuth subsalicylate 2 tablets or capsules four times daily, 30 minutes before meals 1
• Tetracycline HCl 500 mg four times daily, 30 minutes after meals 1
• Metronidazole 500 mg four times daily, 30 minutes after meals 1
• High-dose PPI (esomeprazole or rabeprazole 40 mg) twice daily, 30 minutes before meals 1

Critical: Use esomeprazole 40 mg or rabeprazole 40 mg twice daily—avoid pantoprazole due to inferior potency (40 mg pantoprazole equals only 9 mg omeprazole equivalent, which is inadequate). 1

This regimen is strongly recommended in areas with high clarithromycin resistance (>15-20%), which now includes most regions globally. 1, 2

Alternative First-Line Option (Low Resistance Areas Only)

In areas with documented low clarithromycin resistance (<15%), PPI-clarithromycin-amoxicillin triple therapy for 14 days may be used 3:

• High-dose PPI (esomeprazole or rabeprazole 40 mg) twice daily 1
• Clarithromycin 500 mg twice daily 3
• Amoxicillin 1000 mg twice daily 4

However, clarithromycin-based triple therapy shows decreasing effectiveness due to increasing antibiotic resistance, making bismuth quadruple therapy the preferred standard. 2

Second-Line Treatment After First-Line Failure

After failure of first-line therapy, use either 1:

• Levofloxacin-containing triple therapy (if not previously used and local resistance is low) 3
• Alternative bismuth quadruple therapy (if levofloxacin resistance is high) 3

Caution: Fluoroquinolones should be last-choice options due to serious side effects including tendon rupture and cartilage damage. 1

Third-Line Treatment

After two failed eradication attempts 1:

• Obtain antimicrobial susceptibility testing whenever possible to guide therapy 1
• Rifabutin triple therapy for 14 days is an effective salvage option 1:
  • Rifabutin 150 mg twice daily 1
  • Amoxicillin 1 gram three times daily 1
  • Esomeprazole or rabeprazole 40 mg twice daily 1

Special Clinical Situations

Patients with Penicillin Allergy

• In low clarithromycin resistance areas: PPI-clarithromycin-metronidazole combination 1
• In high clarithromycin resistance areas: Bismuth-containing quadruple therapy (already penicillin-free) 1

Patients on Long-Term PPIs

Eradicate H. pylori in all patients requiring long-term PPI therapy, as H. pylori-positive patients on PPIs develop corpus-predominant gastritis that accelerates progression to atrophic gastritis. 3 Eradication heals gastritis and prevents progression to atrophy. 3

Patients on NSAIDs or Aspirin

• Test and eradicate H. pylori before initiating chronic NSAID therapy—this is mandatory in patients with peptic ulcer history. 3
• Test and eradicate in aspirin users with history of gastroduodenal ulcer, as the long-term risk of peptic ulcer bleeding is very low after successful eradication even without gastroprotective treatment. 3
• H. pylori infection increases the risk of uncomplicated and complicated gastroduodenal ulcers in NSAID and low-dose aspirin users. 3

Patients with Gastric MALT Lymphoma

H. pylori eradication is first-line treatment for low-grade gastric MALT lymphoma, achieving cure in 60-80% of early-stage cases. 3 However, when t(11;18) translocation is present, eradication is usually ineffective and patients need chemotherapy or radiotherapy. 3

Patients with Advanced Gastritis or Atrophy

Eradication therapy is strongly recommended in cases with advanced and progressively worsening forms of gastritis, particularly patients with intestinal metaplasia. 3 Successful eradication is associated with decreased recurrence rates in patients who undergo endoscopic resection of early gastric cancer. 3

Confirmation of Eradication

Confirm eradication in all patients at least 4 weeks after completing treatment using 1, 5:

• Urea breath test (UBT) or laboratory-based validated monoclonal stool antigen test for most patients 1, 5
• Endoscopy with biopsy (two from antrum, two from body, plus one for rapid urease test) for patients with complicated peptic ulcer disease, gastric ulcer, or MALT lymphoma 3, 1

Critical timing requirements before testing 1, 5:

• Stop antibiotics and bismuth at least 4 weeks before testing 1, 5
• Stop PPIs at least 2 weeks before testing 5
• Stop sucralfate at least 4 weeks before testing 1

Failure to observe these intervals will yield false-negative results. 1, 5

Why Eradication is Mandatory in All H. pylori Gastritis

H. pylori induces chronic gastritis in virtually all infected subjects. 6 This inflammation leads to 6, 7:

• Peptic ulceration in a considerable number of infected subjects 6
• Atrophic gastritis with progression over time 6
• Gastric cancer in a minority, but representing the main modifiable risk factor 7

Successful H. pylori eradication reduces the risk of developing gastric cancer in first-degree relatives of gastric cancer patients by 73%. 2 In patients with successful endoscopic treatment of early gastric cancer, eradication halves the rate of metachronous gastric cancer. 2

Eradication cures gastritis in all cases, with complete resolution of inflammation occurring in 4-5 weeks after successful treatment in mild to moderate gastritis. 8 Even severe gastritis shows subsidence of inflammatory changes, though some irreparable mucosal damage may persist. 8

Common Pitfalls to Avoid

• Never use clarithromycin triple therapy empirically without confirmed susceptibility—resistance rates now exceed 15-20% in most regions 1, 2
• Never use obsolete regimens such as concomitant, hybrid, reverse hybrid, or sequential therapies, as they expose patients to antibiotics providing no therapeutic benefit while increasing antimicrobial resistance 1
• Never use 7-day treatment duration—14 days is required for adequate eradication rates 1
• Never test for H. pylori while patient is on PPIs, antibiotics, bismuth, or sucralfate—wait appropriate intervals to avoid false-negative results 1, 5
• Never use H2-receptor antagonists instead of PPIs in eradication regimens—they are inadequate 3
• Never assume eradication without confirmation testing, especially in complicated peptic ulcer disease, gastric ulcer, and MALT lymphoma 3, 1