“How is H.pylori infection treated?”
My mother has been diagnosed with H.pylori infection and it has affected her stomach badly. She is unable to retain food due to this and has become very weak. What is the treatment for this infection?
4 Answers
Triple therapy
Triple therapy for H pylori infection remains an option for first-line therapy in areas of low (< 15%) clarithromycin resistance [4] and consists of the following:
Proton pump inhibitor (PPI) (eg, omeprazole 20 mg BID, lansoprazole 30 mg BID, esomeprazole 40 mg QD, pantoprazole 40 mg QD, rabeprazole 20 mg BID) [5, 6] plus
Clarithromycin 500 mg BID [5] (first-line and continues to be recommended in areas where H pylori clarithromycin resistance is less than 15% and in patients without previous macrolide exposure [2] ) or metronidazole 500 mg BID [5] (when clarithromycin resistance is increasing) [7, 8] plus
Amoxicillin 1000 mg BID [5] or metronidazole 500 mg BID [9] (if not already selected)
Duration
A Cochrane meta-analysis of 55 studies concluded that 14 days is the optimal duration of triple therapy, achieving an H pylori eradication rate of 81.9%, whereas 7 days attains an eradication rate of only 72.9%. [10] In more recent studies, however, the eradication rate with 14-day triple therapy is not significantly different from that with 10-day sequential therapy (amoxicillin and a PPI for 5 days followed by a PPI, clarithromycin and metronidazole for another 5 days) [11] or 10-day concomitant nonbismuth quadruple therapy. [12]
Nonbismuth quadruple therapy
Nonbismuth quadruple therapy may be given sequentially or concomitantly. [3]
Sequential therapy
Sequential therapy (a suggested first-line option [2] ) is superior to standard triple therapy, according to two systematic reviews, [13, 14] and consists of the following:
PPI plus amoxicillin for 5-7 days (eg, pantoprazole 40 mg BID and amoxicillin 1 g BID for 7 days [15] ), then
PPI plus 2 other antibiotics for the next 5-7 days; clarithromycin and metronidazole are the antibiotics usually chosen, but levofloxacin-based regimens (see below) [13, 16, 17] and tetracycline-based regimens (eg, pantoprazole 40 mg BID, tetracycline 500 mg QID, and metronidazole 500 mg BID) [15] are superior to 14-day triple therapy, based on a meta-analysis of 21 trials [13]
Eradication rates with different durations of sequential therapy are as follows:
14 days: 90.7-92.5% eradication rates [18, 19]
10 days: 87% eradication rate [6, 5, 18]
Concomitant therapy
Concomitant therapy (an alternative first-line option [2] ) consists of the following (using dosages similar to those in triple therapy; or all drugs BID in one study):
PPI plus
Amoxicillin plus
Clarithromycin (1 g modified-release tablet QD in one study) plus
Metronidazole (500 mg TID in one study)
Duration of concomitant therapy is 10-14 days. [20, 21, 6]
Concomitant therapy is better for clarithromycin-resistant strains, [20, 4] and 14 days of concomitant therapy is superior to 14-day triple therapy, with cure rates of ≥90%. [22, 23, 24, 25]
Triple therapy for H pylori infection remains an option for first-line therapy in areas of low (< 15%) clarithromycin resistance [4] and consists of the following:
Proton pump inhibitor (PPI) (eg, omeprazole 20 mg BID, lansoprazole 30 mg BID, esomeprazole 40 mg QD, pantoprazole 40 mg QD, rabeprazole 20 mg BID) [5, 6] plus
Clarithromycin 500 mg BID [5] (first-line and continues to be recommended in areas where H pylori clarithromycin resistance is less than 15% and in patients without previous macrolide exposure [2] ) or metronidazole 500 mg BID [5] (when clarithromycin resistance is increasing) [7, 8] plus
Amoxicillin 1000 mg BID [5] or metronidazole 500 mg BID [9] (if not already selected)
Duration
A Cochrane meta-analysis of 55 studies concluded that 14 days is the optimal duration of triple therapy, achieving an H pylori eradication rate of 81.9%, whereas 7 days attains an eradication rate of only 72.9%. [10] In more recent studies, however, the eradication rate with 14-day triple therapy is not significantly different from that with 10-day sequential therapy (amoxicillin and a PPI for 5 days followed by a PPI, clarithromycin and metronidazole for another 5 days) [11] or 10-day concomitant nonbismuth quadruple therapy. [12]
Nonbismuth quadruple therapy
Nonbismuth quadruple therapy may be given sequentially or concomitantly. [3]
Sequential therapy
Sequential therapy (a suggested first-line option [2] ) is superior to standard triple therapy, according to two systematic reviews, [13, 14] and consists of the following:
PPI plus amoxicillin for 5-7 days (eg, pantoprazole 40 mg BID and amoxicillin 1 g BID for 7 days [15] ), then
PPI plus 2 other antibiotics for the next 5-7 days; clarithromycin and metronidazole are the antibiotics usually chosen, but levofloxacin-based regimens (see below) [13, 16, 17] and tetracycline-based regimens (eg, pantoprazole 40 mg BID, tetracycline 500 mg QID, and metronidazole 500 mg BID) [15] are superior to 14-day triple therapy, based on a meta-analysis of 21 trials [13]
Eradication rates with different durations of sequential therapy are as follows:
14 days: 90.7-92.5% eradication rates [18, 19]
10 days: 87% eradication rate [6, 5, 18]
Concomitant therapy
Concomitant therapy (an alternative first-line option [2] ) consists of the following (using dosages similar to those in triple therapy; or all drugs BID in one study):
PPI plus
Amoxicillin plus
Clarithromycin (1 g modified-release tablet QD in one study) plus
Metronidazole (500 mg TID in one study)
Duration of concomitant therapy is 10-14 days. [20, 21, 6]
Concomitant therapy is better for clarithromycin-resistant strains, [20, 4] and 14 days of concomitant therapy is superior to 14-day triple therapy, with cure rates of ≥90%. [22, 23, 24, 25]
Usually with 2 to 3 medications which includes an antibiotic at the same time and may require several treatments. Should eventually require an endoscopy
H pylori is treated with a triple combination of Peptobismol and two common antibiotics, generally followed by Omeprazole. The organism is present and contributes to 98% of duodenal ulcers. Eradication prevents ulcer recurrence.
Maira Jessica Medellin-Peña
Infectious Disease Specialist
The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults published in 2016 in the Gastroenterology Journal (Gastroenterology 2016;151:51–69).
Optimal treatment of H. pylori infection requires careful attention to local antibiotic resistance and eradication patterns. The quadruple therapies PAMC* or PBMT* can help in the eradication of H. pylori infection, and all treatments should be given for 14 days. PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole) is restricted to areas that have low clarithromycin resistance or high eradication success with the triple therapy regimens.
*Non-bismuth quadruple therapy (Proton pump inhibitor + Amoxicillin + Metronidazole + Clarithromycin) and traditional bismuth quadruple therapy (PPI |+ bismuth + metronidazole + tetracycline).
Optimal treatment of H. pylori infection requires careful attention to local antibiotic resistance and eradication patterns. The quadruple therapies PAMC* or PBMT* can help in the eradication of H. pylori infection, and all treatments should be given for 14 days. PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole) is restricted to areas that have low clarithromycin resistance or high eradication success with the triple therapy regimens.
*Non-bismuth quadruple therapy (Proton pump inhibitor + Amoxicillin + Metronidazole + Clarithromycin) and traditional bismuth quadruple therapy (PPI |+ bismuth + metronidazole + tetracycline).
