Helicobacter pylori eradication therapy

What are the recommendations for management of H. pylori infection this week?

Clarithromycin and metronidazole have high emergent resistance. It helps to know if that is the case in your area. If not, and assuming no recent exposure to clarithromycin- or metronidazole-based therapy for the person in front of you, then a 14-day triple-therapy — amoxycillin / metronidazole / clarithromycin — with a PPI is a reasonable option.

[Levofloxacin may be used instead of clarithromycin but it is less well tolerated and is also prone to rapid emergence of resistance.]

Otherwise, bismuth-based quadruple therapy for 14 days seems to be the new standard (NNT = 3 -12). Of note, Amoxycillin and tetracycline have both retained low resistance patterns in the order of 1-3%.

Probiotics are not helpful.

Conclusion

Current standard of care for H. pylori infection is 14-day quadruple therapy:

1. bismuth — beptabismol, bismuth salicylate (care with concomitant NSAIDs, anticoagulants), or bismuth subcitrate
2. amoxycillin
3. metronidazole
4. tetracycline

References

• Helicobacter pylori Treatment: The ‘Rules’ Have Changed – Medscape, August 30, 2016