Helicobacter Pylori Eradication Regimens

First-Line Treatment Recommendations

The American Gastroenterological Association recommends a 14-day quadruple therapy with bismuth as the first-line treatment for Helicobacter pylori eradication, especially in areas with high clarithromycin resistance 1, 2
The choice of eradication regimen should be based on local patterns of antibiotic resistance, especially to clarithromycin, patient's previous exposure to antibiotics 1, 3, 4, and availability of bismuth in the region 1, 5
Quadruple therapy with bismuth, consisting of a proton pump inhibitor (PPI) twice a day, bismuth subsalicylate or subcitrato four times a day 4, metronidazol 500 mg three or four times a day 6, and tetracycline 500 mg four times a day 7, for 14 days, is a recommended first-line treatment 1, 2

After failure of a clarithromycin-containing treatment, a quadruple therapy with bismuth (if not previously used) or a triple therapy with levofloxacino can be considered 1, 2, 6
The triple therapy with levofloxacino consists of a PPI twice a day, amoxicilina 1000 mg twice a day, and levofloxacino 500 mg once a day or 250 mg twice a day, for 14 days 1, 2

Using high-dose PPI (twice a day) can increase the efficacy of the treatment 3, 8
Extending the treatment duration to 14 days can improve eradication rates by approximately 5% 3, 6
The use of probiotics as an adjunctive treatment can help reduce side effects 3, 7

A breath test with urea or a stool antigen test should be performed 8 weeks after treatment to confirm eradication 2, 3
Serology should not be used to confirm eradication 3

In patients allergic to penicillin, amoxicilina can be replaced with tetracycline 7
In children, fluoroquinolones and tetracyclines should not be used, limiting treatment options 7
After failure of a second treatment, antimicrobial susceptibility testing is recommended whenever possible 3, 6