From the Guidelines
The most current treatment for H. pylori infection is a 14-day quadruple therapy regimen consisting of a proton pump inhibitor (PPI) such as omeprazole 20mg twice daily, bismuth subsalicylate 524mg four times daily, tetracycline 500mg four times daily, and metronidazole 500mg three times daily, as recommended by recent guidelines 1. This regimen, often referred to as bismuth quadruple therapy, is favored due to increasing antibiotic resistance and has been shown to achieve high cure rates 1.
Key Considerations
- The choice of treatment regimen should be based on local resistance patterns and previous antibiotic exposure 1.
- Alternative regimens, such as concomitant therapy (PPI, amoxicillin, clarithromycin, and metronidazole) or sequential therapy, may be considered depending on local resistance patterns 1.
- The duration of treatment is crucial, with 14 days being the recommended duration for most regimens 1.
- Administration of the PPI 30 minutes before meals and the antibiotics 30 minutes after meals may be important for achieving high cure rates, although this parameter needs further evaluation 1.
Importance of Treatment Success
Treatment success is crucial because H. pylori causes chronic gastritis, peptic ulcers, and is associated with gastric cancer 1. The bacterium survives in the acidic stomach environment by producing urease, which neutralizes stomach acid around it, making acid suppression with PPIs an essential component of effective treatment regimens.
Follow-up Testing
After completing treatment, patients should undergo testing to confirm eradication, typically using a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after therapy and after stopping PPI for 2 weeks 1. This ensures that the treatment has been effective and reduces the risk of complications.
Antimicrobial Stewardship
The use of antimicrobial stewardship is essential in optimizing H. pylori treatment regimens, with a focus on using only optimized, directly or indirectly susceptibility-guided therapy 1. This approach simplifies the treatment options and ensures that patients receive the most effective treatment regimen for their specific infection.
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.
The most current treatment for H. pylori mentioned in the label is:
- Triple therapy: Amoxicillin, clarithromycin, and lansoprazole
- Dual therapy: Amoxicillin and lansoprazole (for patients allergic or intolerant to clarithromycin or with known/suspected resistance to clarithromycin) 2
From the Research
Current Treatment for H. pylori
The current treatment for H. pylori infection involves various regimens, including:
- Quadruple therapy with a proton pump inhibitor (PPI), two antibiotics, and bismuth 3
- Levofloxacin-based therapy as a second-line treatment after failure of non-bismuth quadruple therapy 4
- Azithromycin, ofloxacin, bismuth, and omeprazole as a second-line therapy 5
- A combination of a PPI, amoxicillin, and metronidazole for retreatment after initial treatment failure 6
Treatment Regimens
Some specific treatment regimens that have been studied include:
- Amoxicillin, metronidazole, omeprazole, and clarithromycin for 5 days 7
- Levofloxacin, bismuth, amoxicillin, and esomeprazole for 14 days 4
- Azithromycin, ofloxacin, bismuth, and omeprazole for 2 weeks 5
- Rabeprazole, lansoprazole, or omeprazole plus amoxicillin and metronidazole for 7 days 6
Factors Affecting Treatment Efficacy
The efficacy of treatment can be affected by various factors, including: