Eradication of H pylori has proved difficult. Combination regimens that use two or three antibiotics with a proton pump inhibitor or bismuth are required to achieve adequate rates of eradication and to reduce the number of failures due to antibiotic resistance. In the United States, up to 50% of strains are resistant to metronidazole and 13% are resistant to clarithromycin.

Helicobacter pylori  Treatment

Eradication of H pylori

At present, experts disagree on the optimal regimen; however, updated Maastricht consensus guidelines were published in 2012. In areas of low clarithromycin resistance, including the United States, a 14-day course of “triple therapy, ” with an oral proton pump inhibitor, clarithromycin 500 mg, and amoxicillin 1 g (or, if penicillin allergic, metronidazole 500 mg), all given twice daily for 14 days, is still recommended for first-line therapy. Unfortunately, this regimen only achieves rates of eradication > 75%. “Quadruple therapy, ” with a proton pump inhibitor, bismuth, tetracycline, and metronidazole or tinidazole for 14 days is a more complicated but also more effective regimen. In a 2011 randomized, controlled trial, the per protocol eradication rates were 93% with quadruple therapy and 70% with triple therapy. Bismuth-based quadruple therapy is recommended as firstline therapy for patients in areas with high clarithromycin resistance (> 20%), in patients who have previously been treated with a macrolide antibiotic, or as second-line therapy for patients whose infection persists after an initial course of triple therapy.

Several studies reported eradication rates of > 90% using a 10-day sequential regimen consisting of four drugs: a proton pump inhibitor and amoxicillin for 5 days, followed by a proton pump inhibitor, clarithromycin, and tinidazole for 5 days. However, subsequent studies confirmed equivalent or superior efficacy when all four drugs were given concomitantly for 10 days (non-bismuth quadruple therapy). Unfortunately, recent studies have reported lower eradication rates with sequential therapy, and a 2013 meta-analysis did not detect superiority compared with 14-day triple therapy or bismuth-based therapy, except in patients with organisms exhibiting clarithromycin resistance. Most recently, a 2013 large multicenter European controlled trial conducted in regions of high clarithromycin resistance reported 92% eradication with a 14-day quadruple therapy consisting of a proton pump inhibitor, amoxicillin, clarithromycin, and nitroimidazole (the latter not available in the United States).

Patients should be encouraged to eat balanced meals at regular intervals. There is no justification for bland or restrictive diets. Moderate alcohol intake is not harmful. Smoking retards the rate of ulcer healing and increases the frequency of recurrences and should be prohibited.


Disclaimer: This article on H. Pylori Treatment (Eradication) has been written and presented strictly for informational and educational purposes only. Please seek advice from a health professional.

Read More About H. Pylori

Helicobacter pylori  Stomach Cancer