What is the recommended treatment for Helicobacter pylori (H. pylori) using quadruple therapy?

From the Guidelines

Quadruple therapy for H. pylori infection should consist of a 14-day bismuth quadruple therapy regimen, including a proton pump inhibitor (PPI), bismuth subsalicylate, tetracycline, and metronidazole, as it is the preferred first-line therapy in the face of increasing antibiotic resistance 1. The most common regimen is bismuth quadruple therapy, which includes a PPI (such as omeprazole 20mg or equivalent twice daily), bismuth subsalicylate (525mg four times daily), tetracycline (500mg four times daily), and metronidazole (500mg three to four times daily) 1. Some key points to consider when prescribing quadruple therapy for H. pylori infection include:

• The importance of completing the full 14-day course of treatment to ensure eradication
• The need to avoid alcohol during treatment due to potential interactions with metronidazole
• The synergistic effect of the multiple antibiotics in overcoming resistance patterns
• The role of the PPI in creating a less acidic environment in the stomach, enhancing antibiotic efficacy and allowing H. pylori to be more susceptible to treatment Alternative non-bismuth quadruple therapy regimens, such as concomitant therapy, may also be effective, but bismuth quadruple therapy is generally preferred due to its high efficacy and ability to overcome resistance patterns 1. Key considerations for prescribing quadruple therapy include:
• Patient compliance and ability to complete the full course of treatment
• Potential interactions with other medications, such as alcohol
• Regional antibiotic resistance patterns and the need for susceptibility testing or regional data to guide treatment decisions
• The importance of antibiotic stewardship and the need to balance treatment efficacy with the risk of promoting further antibiotic resistance.

From the Research

H. pylori Quadruple Therapy

• H. pylori infection is a common worldwide infection that can cause peptic ulcer disease and gastric cancer 2.
• Quadruple therapy is a treatment option for H. pylori infection, which typically includes a proton pump inhibitor, bismuth, and two antibiotics such as amoxicillin and metronidazole or clarithromycin 2, 3.
• The choice of treatment regimen should be based on previous antibiotic exposure and regional resistance patterns 2, 3.
• Bismuth quadruple therapy is a recommended first-line treatment option, especially in areas with high clarithromycin resistance rates 2, 3.

Efficacy of Quadruple Therapy

• Studies have shown that quadruple therapy can achieve high eradication rates, ranging from 85.9% to 100% 4, 5.
• A study comparing proton pump inhibitor-amoxicillin-clarithromycin with proton pump inhibitor-amoxicillin-metronidazole found that the latter regimen was more effective, with intention-to-treat and per-protocol eradication rates of 96.4% and 100%, respectively 5.
• Another study found that patients with a high intragastric bacterial load may benefit from an extension to 2 weeks of triple therapy with lansoprazole, amoxycillin, and clarithromycin 4.

Treatment Recommendations

• The American College of Gastroenterology recommends bismuth quadruple therapy or concomitant therapy as first-line treatment options for H. pylori infection 2.
• If first-line therapy fails, a salvage regimen should avoid antibiotics that were previously used, and bismuth quadruple therapy or levofloxacin salvage regimens are preferred treatment options 2.
• It is essential to test for eradication after treatment, as untreated H. pylori infection can lead to serious complications such as peptic ulcer disease and gastric cancer 3.