July 29, 2017
This is part three of a special three-part series on the bacteria known as H. pylori. Read part two for the testing methods which can be found in our blog portion of the website.
Treatment regimens for H. pylori are varied and can prove to be quite effective. For example, the bismuth quadruple therapy can result in an eradication rate of up to 90%. To ease the complexity of quadruple therapy, the combination of the drugs Helidac and Pylera can be used. Individuals diagnosed with H. pylori who are pregnant or lactating should be treated initially with acid-suppression until antibiotics can be administered after delivery.
First line treatment: PPI BID + clarithromycin 500 mg BID + amoxicillin 1 g BID or metronidazole
500 mg BID for 14 days
Alternative treatment: PPI or H-2 blocker BID +bismuth QID + metronidazole 250 mg QID + tetracycline 500 mg QID for 10-14 days
Mild side effects are common with all H. pylori treatments; only 5-20% of patients report significant side effects. Despite this, all patients should be informed of the side effects and encouraged to complete treatment as long as the effects are mild. Headache and diarrhea are the most commonly reported side effects. Side effects due to clarithromycin use include altered taste, GI upset and diarrhea. Diarrhea or a rash can also be a side effect of amoxicillin use. Side effects of metronidazole tend to be dose-related and include dyspepsia, a metallic taste, and a disulfiram-like reaction with alcohol consumption. Bismuth can lead to darkening of the stool and tongue, nausea and constipation.
Eradication rates for H. pylori may be decreasing due to antibiotic resistance: metronidazole resistance is common (22-39%); clarithromycin resistance is relatively low (<13%); and resistance to amoxicillin or tetracycline is rare. Previous treatment with either a macrolide or metronidazole for any reason significantly increases the likelihood of H. pylori resistance. So, if a patient fails an initial course of H. pylori treatment, antibiotics that have been previously taken by the patient should be avoided. Biopsies for culture and resistance testing are not routinely recommended, but can be performed for difficult cases.
Confirmation of eradication for H. pylori after treatment is recommended for the following:
H. pylori-associated ulcer
Persistent dyspeptic symptoms despite the test-and-treat strategy
H. pylori-associated MALT lymphoma
After resection of early gastric cancer
The reinfection rate for H. pylori after successful eradication is low (1-2% per year). Persistent infection is more likely due to relapse from inadequate treatment.