From the Guidelines
The most effective treatment for H pylori infection is a 14-day course of bismuth quadruple therapy, which is favored due to its high success rate even in areas with high dual resistance to clarithromycin and metronidazole. This recommendation is based on the most recent guidelines, which emphasize the importance of succeeding on the first attempt to avoid retreating and retesting, and reducing cost, anxiety, and negative impacts on other gut microbiota 1.
First-Line Therapy Options
- Bismuth quadruple therapy is recommended, particularly in areas of high dual resistance to clarithromycin and metronidazole, as it avoids the potential problem of antibiotic overuse and has acceptable success even in strains displaying in vitro metronidazole resistance.
- Concomitant therapy is also an option for patients from areas of high clarithromycin resistance where bismuth is not available.
- The use of levofloxacin as a first-line therapy is not recommended, except in patients from areas of high dual resistance and low levofloxacin resistance, and only if bismuth is not available.
Treatment Duration
- A 14-day course of treatment is recommended for all first-line therapies, as it has been shown to have a higher success rate compared to shorter durations 1.
Importance of Treatment
- H pylori infection causes chronic gastritis and increases the risk for peptic ulcers and gastric cancer, making treatment essential to prevent these complications.
- The bacterium survives in the acidic stomach environment by producing urease, which neutralizes stomach acid in its immediate vicinity, making acid suppression with PPIs an essential component of effective treatment.
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.
H. pylori treatment options with amoxicillin include:
- 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 clarithromycin resistance 2
From the Research
H pylori Treatment Options
- The efficacy of triple therapy containing clarithromycin, the current standard treatment for Helicobacter pylori infection, is declining due to increasing antibiotic resistance 3.
- Quadruple therapies, such as bismuth quadruple and concomitant therapies, are recommended as first-line treatments for H. pylori infection, especially in areas with high clarithromycin resistance 4.
- A 14-day clarithromycin-containing triple therapy may be suggested in areas with low prevalence of clarithromycin resistance and in patients without previous use of macrolides 4.
Second-Line Treatment Options
- Second-line treatments for H. pylori infection include levofloxacin-containing triple therapy and bismuth quadruple therapy 4.
- A new quadruple therapy regimen consisting of azithromycin, ofloxacin, bismuth, and omeprazole has been shown to be effective and safe as a second-line therapy for H. pylori eradication 5.
Treatment Efficacy and Safety
- The eradication rate of H. pylori for patients under quadruple treatment has been reported to be around 96% without previous dual therapy and 92% with previous dual therapy 6.
- A study comparing the efficacy and safety of azithromycin, ofloxacin, bismuth, and omeprazole with amoxicillin, clarithromycin, bismuth, and omeprazole as second-line therapy found that the new quadruple therapy regimen had a higher eradication rate (77.3% vs 64.5%) and fewer side effects 5.
- Triple therapy with omeprazole, clarithromycin, and amoxicillin has been shown to be an effective and well-tolerated treatment for H. pylori infection, with eradication rates of 89.6% and 95.7% for 1-week and 2-week treatments, respectively 7.