Bismuth Quadruple Therapy for H. pylori Eradication

Complete Regimen Components and Dosing

The standard bismuth quadruple therapy regimen consists of bismuth subsalicylate 120-140 mg (or 262 mg depending on formulation) 3-4 times daily, tetracycline 500 mg 4 times daily, metronidazole 500 mg 3-4 times daily, and a proton pump inhibitor at standard dose twice daily for 14 days 1, 2, 3
Bismuth subsalicylate: 120-140 mg 3-4 times daily or 262 mg (depending on formulation) 2 tablets 3-4 times daily 1, 2, 3
Tetracycline: 500 mg 4 times daily 1, 3
Metronidazole: 500 mg 3-4 times daily or 400 mg 4 times daily 1, 2, 3
Proton pump inhibitor (PPI): Standard dose twice daily, with standard PPI doses including dexlansoprazole 30 mg, esomeprazole 20 mg, lansoprazole 30 mg, omeprazole 20 mg, pantoprazole 40 mg, rabeprazole 20 mg 1, 2, 4

The recommended duration is 14 days according to Toronto Consensus and Maastricht V/Florence Consensus 1, 2
American College of Gastroenterology (ACG) considers 10-14 days adequate 1, 2

Bismuth quadruple therapy is recommended as first-line treatment in areas with high clarithromycin resistance (>15-20%) 2, 3
It's also recommended as second-line therapy after failure of clarithromycin-based regimens 1, 4
The addition of bismuth improves treatment efficacy, especially in the presence of metronidazole resistance 3
Metronidazole resistance can be partially overcome by increasing the dose and duration of treatment 3
Doxycycline should not be substituted for tetracycline due to inferior results 3
For patients with penicillin allergy, bismuth quadruple therapy is preferred over clarithromycin-based regimens 1

Complete the full course of treatment to maximize eradication rates 2
Take PPI 30 minutes before eating on an empty stomach 4
Avoid concomitant use of other antacids such as H2-receptor antagonists 4
Consider local antibiotic resistance patterns when selecting therapy 2, 3
After two failed therapies, H. pylori susceptibility testing should be considered 4