Health Questions and Answers

Question: What treatment regimens have been used to eradicate Helicobacter pylori?


The preferred initial treatment for H. pylori infection is a 10- to 14-day course of PPI triple therapy (PPI, amoxicillin 1000 mg, and clarithromycin 500 mg, all given twice daily), and this can successfully cure infection in >80% of individuals. Metronidazole 500 mg can be substituted for amoxicillin, but this should be done only in penicillin-sensitive individuals because of the high rate of metronidazole resistance. Those in whom this treatment fails (positive stool, breath, or endoscopic test after treatment) should not be retreated with clarithromycin because of presumed acquired macrolide resistance. An appropriate second treatment regimen is a 2-week course of quadruple therapy (PPI b.i.d. plus bismuth subsalicylate [PeptoBismol] two tabs, tetracycline 500 mg, and metronidazole 500 mg four times daily). Although third and even fourth courses of this quadruple therapy are sometimes successful in curing persistent infection, rifabutin, quinolone, or furazolidone-based therapies may be more suitable for particularly refractory cases.

Reference:  McMahon BJ, Hennessy TW, Bensler JM, et al: The relationship among previous antimicrobial use, antimicrobial resistance, and treatment outcomes for Helicobacter pylori infections. Ann Intern Med 139:463-469, 2003.

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