From the Guidelines
Outpatient treatment for H. pylori infection should consist of a 14-day course of bismuth quadruple therapy or concomitant therapy, as these regimens have been shown to have higher success rates and are recommended by recent guidelines. The choice of therapy should be based on previous antibiotic exposure or known local prevalence of resistant organisms 1.
First-Line Therapy Options
- Bismuth quadruple therapy is favored, 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 1.
- Concomitant therapy is appropriate for those patients from areas of high clarithromycin resistance where bismuth is not available 1.
Duration of Therapy
- A 14-day duration is recommended for all first-line treatments, as it has been shown to have higher success rates compared to shorter durations 1.
Importance of Treatment
- Eradication of H. pylori is important as it can cause chronic gastritis, peptic ulcers, and is associated with gastric cancer.
- Treatment failure may occur due to antibiotic resistance, poor compliance, or inadequate acid suppression, potentially requiring second-line therapy with different antibiotics.
Patient Advice
- Patients should be advised to take medications as prescribed for the full duration, even if symptoms improve, and to avoid alcohol during treatment, especially when taking metronidazole.
Confirmation of Treatment Success
- Treatment success should be confirmed with a urea breath test, stool antigen test, or endoscopy at least 4 weeks after completing therapy and after PPI discontinuation for at least 2 weeks.
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 can be done on an outpatient basis using:
- Triple therapy: amoxicillin, clarithromycin, and lansoprazole
- Dual therapy: amoxicillin and lansoprazole, for patients who are allergic or intolerant to clarithromycin or have resistance to clarithromycin 2 3
From the Research
H.pylori Treatment Outpatient
- The treatment of H.pylori infection typically involves a combination of antibiotics and a proton pump inhibitor (PPI) 4, 5.
- The choice of treatment regimen depends on various factors, including the patient's previous antibiotic exposure, the presence of clarithromycin resistance, and the patient's age 4, 5.
- A meta-analysis of 18 studies involving 3264 patients found that proton-pump inhibitor and amoxicillin-based triple therapy containing clarithromycin (PAC) and metronidazole (PAM) had comparable intention-to-treat (ITT) eradication rates (71.0% versus 75.2%) and per-protocol (PP) eradication rates (79.6% versus 80.1%) 4.
- Another study found that bismuth quadruple therapy and concomitant therapy consisting of a PPI, clarithromycin, amoxicillin, and metronidazole were effective first-line treatments for H. pylori infection 5.
- A randomized trial found that PPI-based triple and quadruple therapy with lansoprazole, amoxycillin, and clarithromycin (LAC) and lansoprazole, bismuth, metronidazole, and tetracycline (LBMT) were effective in retreating patients failing initial H. pylori therapy 6.
- A review of current diagnostic and management strategies for H. pylori infection recommended a "test-and-treat" approach and emphasized the importance of considering regional resistance patterns and prior antibiotic exposure when selecting therapy 7.
- A systematic review and meta-analysis found that triple therapy combining a proton-pump inhibitor, amoxicillin, and metronidazole (PAM) was less efficacious than clarithromycin-including triple therapies, but its efficacy was similar to that of PAC when drugs were administered for 14 days 8.
Treatment Regimens
- PAC: proton-pump inhibitor, amoxicillin, and clarithromycin 4, 5
- PAM: proton-pump inhibitor, amoxicillin, and metronidazole 4, 8
- Bismuth quadruple therapy: bismuth subsalicylate, metronidazole, tetracycline, and a proton-pump inhibitor 5, 6
- Concomitant therapy: a proton-pump inhibitor, clarithromycin, amoxicillin, and metronidazole 5