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

From the Guidelines

The most effective treatment for H. pylori infection is a 14-day quadruple therapy consisting of a proton pump inhibitor (PPI), bismuth subsalicylate, tetracycline, and metronidazole, as it provides the highest success rate and minimizes the risk of antibiotic resistance 1.

First-Line Therapy Options

The choice of first-line therapy depends on the local prevalence of resistant organisms and previous antibiotic exposure.

• Bismuth quadruple therapy is recommended in areas with high dual resistance to clarithromycin and metronidazole.
• Concomitant therapy is suitable for patients from areas with high clarithromycin resistance where bismuth is not available.
• Clarithromycin triple therapy can be used in regions with low clarithromycin resistance.

Treatment Duration

The recommended duration of first-line therapies is 14 days, as it provides higher success rates compared to shorter durations 1.

Second-Line Therapy

In cases of treatment failure, a 10-day levofloxacin-amoxicillin triple therapy can be used as a second-line option 1.

Importance of Eradication

Eradication of H. pylori is crucial to prevent chronic gastritis, peptic ulcers, and gastric cancer.

• Patients should avoid alcohol during treatment, especially when taking metronidazole.
• Potential side effects include nausea, metallic taste, and diarrhea.

Antibiotic Resistance

Antibiotic resistance is increasing, and treatment failure may require culture and sensitivity testing to guide second-line therapy 1.

Key Considerations

• The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community.
• Treatment success should be confirmed with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and after stopping PPI for 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 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

• First-line treatments for H pylori infection include concomitant nonbismuth quadruple therapy (proton pump inhibitor + amoxicillin + metronidazole + clarithromycin) and traditional bismuth quadruple therapy (proton pump inhibitor + bismuth + metronidazole + tetracycline) for 14 days 3
• PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole) is restricted to areas with known low clarithromycin resistance or high eradication success with these regimens 3
• Recommended rescue therapies include bismuth quadruple therapy and levofloxacin-containing therapy (PPI + amoxicillin + levofloxacin) 3

Duration of Treatment

• The consensus group strongly recommends that all H pylori eradication regimens be given for 14 days due to increasing failure of therapy 3
• A 14-day treatment duration is also recommended in other studies, including those using dual therapies containing an antibiotic plus a proton pump inhibitor or vonoprazan 4

Alternative Treatment Options

• Dual therapies containing an antibiotic plus a proton pump inhibitor or vonoprazan may be effective alternatives for H pylori treatment, with pooled eradication rates of 86.1-93.0% 4
• Tetracycline/vonoprazan dual therapy may be an effective option for eradicating H pylori in patients allergic to penicillin, with eradication rates of 92.0-95.1% 4

Guidelines and Recommendations

• The American College of Gastroenterology recommends bismuth quadruple therapy for 14 days as the preferred regimen for treatment-naive patients with H pylori infection when antibiotic susceptibility is unknown 5
• The choice of H pylori eradication regimen should be based on the local prevalence of clarithromycin resistance and the previous use of macrolides 6