What is the treatment for Helicobacter pylori (H. pylori) infection?

From the Guidelines

Helicobacter pylori infection is typically treated with a combination therapy approach known as triple or quadruple therapy, with the standard first-line treatment consisting of a proton pump inhibitor (PPI) such as omeprazole, amoxicillin, and clarithromycin for 14 days, as recommended by recent guidelines 1. The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community, with standard triple therapy (amoxicillin, clarithromycin, and PPI) recommended as first-line therapy if low clarithromycin resistance is present 1. Some key points to consider when treating H. pylori infection include:

• The use of a PPI to reduce stomach acid production and create a less acidic environment that enhances antibiotic effectiveness and promotes healing of any ulcers 1
• The recommendation for 14 days of treatment, as this has been shown to have higher success rates compared to shorter durations 1
• The consideration of bismuth quadruple therapy in areas with high clarithromycin resistance, which includes a PPI, bismuth subsalicylate, tetracycline, and metronidazole for 10-14 days 1
• The importance of testing to confirm eradication after completing treatment, typically using a urea breath test or stool antigen test at least 4 weeks after therapy and while off PPI medications for at least 2 weeks 1 It is also important to note that the treatment of H. pylori infection should be individualized based on the patient's specific needs and circumstances, and that antibiotic resistance is a growing concern that should be taken into account when selecting a treatment regimen 1. In terms of specific treatment regimens, the following are recommended:
• Standard triple therapy: PPI, amoxicillin 1000mg twice daily, and clarithromycin 500mg twice daily for 14 days 1
• Bismuth quadruple therapy: PPI, bismuth subsalicylate 525mg four times daily, tetracycline 500mg four times daily, and metronidazole 250mg four times daily for 10-14 days 1
• Sequential therapy: PPI and amoxicillin for the first 5 days, followed by PPI, clarithromycin, and metronidazole for the next 5 days 1
• Levofloxacin-amoxicillin triple therapy: PPI, levofloxacin 500mg once daily, and amoxicillin 1000mg twice daily for 10 days, as a second-line therapy if first-line therapy fails 1

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.

Treatment of H. pylori infection involves:

• 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 resistance to clarithromycin 2

From the Research

Treatment Options for H. pylori Infection

• The first-line treatment for H. pylori infection is typically a triple therapy consisting of two antibiotics (such as clarithromycin and amoxicillin or metronidazole) and a proton pump inhibitor (PPI) 3, 4.
• However, due to increasing antibiotic resistance, bismuth-based quadruple therapy has also become a first-line regimen in areas with high rates of clarithromycin and metronidazole resistance 3, 5.
• Concomitant, sequential, and hybrid therapies are also effective bismuth-free quadruple options, especially when dual clarithromycin-metronidazole resistance is low 5.
• Salvage regimens, such as levofloxacin- or rifabutin-containing regimens, can be used if first-line therapy fails 3, 4, 5, 6.

Factors Affecting Treatment Success

• Patient compliance is a major factor in treatment success, with approximately 20% of patients failing to obtain H. pylori eradication due to insufficient compliance 3.
• Antibiotic resistance is another significant factor, with clarithromycin resistance being a major concern 3, 5, 6.
• Previous antibiotic exposure should be taken into account when choosing a treatment regimen 6.

Emerging Therapies and Treatment Strategies

• New drugs and adjuvant agents, such as vonoprazan and certain probiotics, are being developed and may offer improved treatment options 5.
• Susceptibility-guided treatment, which involves testing for antibiotic resistance before treatment, may become a more prominent approach in the future 5.
• Molecular testing methods may also become more widely used to characterize H. pylori antibiotic susceptibility 5.