Helicobacter pylori infection medical therapy
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Indications for treatment of H. pylori infection include past or present duodenal and/or gastric ulcer, with or without complications, following resection of gastric cancer, gastric mucosa-associated lymphoid tissue (MALT) lymphoma, atrophic gastritis, dyspepsia, patients with first-degree relatives with gastric cancer and patient‘s wishes. Factors involved in choosing treatment regimens include prevalence of H. pylori infection, prevalence of gastric cancer, resistance to antibiotics, availability of bismuth, availability of endoscopy and H. pylori tests, ethnicity, drug allergies and tolerance, previous treatments and outcome, adverse effects, effectiveness of local treatment and recommended dosages and treatment duration.
- Past or present duodenal and/or gastric ulcer, with or without complications
- Following resection of gastric cancer
- Gastric mucosa-associated lymphoid tissue (MALT) lymphoma
- Atrophic gastritis
- Patients with first-degree relatives with gastric cancer
- Patients wishes
Factors involved in choosing treatment regimens include:
- Prevalence of H. pylori infection
- Prevalence of gastric cancer
- Resistance to antibiotics
- Availability of bismuth
- Cost of tests
- Availability of endoscopy and H. pylori tests
- Drug allergies and tolerance
- Previous treatments and outcome
- Ease of administration
- Adverse effects
- Effectiveness of local treatment
- Recommended dosages and treatment duration
First-Line Regimens for Helicobacter pylori Eradication
- Bismuth quadruple therapy has been advocated as a primary therapy for H. pylori.
- In patients who have not previously received clarithromycin and who are not allergic to penicillin, PPI, clarithromycin, and amoxicillin are considered.
- For patients allergic to penicillin, metronidazole is given as an alternative for amoxicillin.
- In patients who are allergic to penicillin or those who have previously been treated with a macrolide antibiotic, bismuth quadraple therapy is considered.
|Standard dose PPI b.i.d. (esomeprazole is q.d.),||10–14||70–85%||Consider in nonpenicillin allergic patients who have not previously received a macrolide|
|Standard dose PPI b.i.d., clarithromycin 500 mg b.i.d.
metronidazole 500 mg b.i.d.
|10–14||70–85%||Consider in penicillin allergic patients who have not previously received a macrolide or are unable to tolerate bismuth quadruple therapy|
|Bismuth subsalicylate 525 mg p.o. q.i.d. metronidazole
250 mg p.o. q.i.d., tetracycline 500 mg p.o. q.i.d.,
ranitidine 150 mg p.o. b.i.d. or standard dose
PPI q.d. to b.i.d.
|10–14||75–90%||Consider in penicillin allergic patients|
|PPI + amoxicillin 1 g b.i.d. followed by||5
|>90%||Requires validation in North America|
|PPI = proton pump inhibitor; pcn = penicillin; p.o. = orally; q.d. = daily; b.i.d. = twice daily; t.i.d. = three times daily; q.i.d. = four times daily.
*Standard dosages for PPIs are as follows:
Note: the above-recommended treatments are not all FDA approved.
FDA approved regimens are as follows:
Predictors of H.pylori Treatment Outcome
Predictors of treatment failure include:
- Poor compliance
- Antibiotic resistance (key factor in the failure of eradication therapy and recurrence of H. pylori infection)
- Bacterial factors like CagA-negative strains are at increased risk of treatment failure compared with CagA-positive strains
- CYP2C 19 polymorphisms may influence treatment outcomes when regimens containing PPIs are used as they influence the clearance of PPIs and thus their effect on gastric acid secretion.
|Proton pump inhibitors (PPIs)||
||PPIs should be taken 30-60 min before eating to optimize their effects on gastric acid secretion.|
||Tetracyclinhes should not be given to children under 8 yr of age because of possible tooth discoloration|
Salvage Therapy for Persistent H.pylori Infection
- In patients with persistent H. pylori infection, every effort should be made to avoid antibiotics that have been previously taken by the patient.
- Bismuth-based quadruple therapy for 7-14 days is an accepted salvage therapy.
- Levofloxacin-based triple therapy for 10 days is another option in patients with persistent infection, which requires validation in the United States.
|Bismuth quadruple therapy||7||68%||Accessible, cheap but high pill count, and frequent mild side effects|
|Levofloxacin triple therapy||10||10 87%||Requires validation in North America|
- Triple therapy should be used if a patient has persistent infection who has previously not been treated with clarithromycin.
- In patients who were treated with clarithromycin initially, bismuth quadruple therapy is used as salvage therapy.
Other Alternative Antibiotics
- Rifabutin is used as an alternate antibiotic in patients with clarithromycin or metronidazole resistance.
- Side effects include rash, nausea, vomiting, dyspepsia, diarrhea, myelotoxicity and ocular toxicity
- Furazolidone is used as an alternative to clarithromycin, metronidazole, or amoxicillin
- Not currently used in the United states
- Side effects include nausea, vomiting, headache and malaise
- Levofloxacin-based triple therapy (PPI, levofloxacin, and amoxicillin) can be used as second and third-line therapy in patients with persistent H. pylori infection.
H.pylori Treatment Options in Developing Countries
|PPI + amoxicillin + clarithromycin
(All twice daily for 7 days)
|In case of a clarithromycin resistance rate of more than 20%:||
|If there is no known clarithromycin resistance or clarithromycin resistance is not likely:
|B Second-line therapies, after failure of clarithromycin incontaining regimens|
|C Third-line therapies, after failure of clarithromycin-containing regimens and quadruple therapy|
B.i.d (twice a day); q.i.d (four times a day); PPI, proton-pump inhibitor
Testing to Prove Eradication After Antibiotic Therapy
The following are the indications for testing to prove eradication after antibiotic therapy.
- Any patient with an H.pylori-associated ulcer.
- Individuals with persistent dyspeptic symptoms despite the test-and-treat strategy.
- Those with H.pylori associated MALT lymphoma.
- Individuals who have undergone resection of early gastric cancer.
- Hunt RH, Xiao SD, Megraud F, Leon-Barua R, Bazzoli F, van der Merwe S; et al. (2011). "Helicobacter pylori in developing countries. World Gastroenterology Organisation Global Guideline". J Gastrointestin Liver Dis. 20 (3): 299–304. PMID 21961099.
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