Helicobacter Pylori (H. pylori)

  • Medical Author:
    Charles Patrick Davis, MD, PhD

    Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

  • Medical Editor: Jay W. Marks, MD
    Jay W. Marks, MD

    Jay W. Marks, MD

    Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.

Quick GuideDigestive Disease Myths Pictures Slideshow: Common Misconceptions

Digestive Disease Myths Pictures Slideshow: Common Misconceptions

What is the treatment for H. pylori?

H. pylori is difficult to eradicate from the stomach because it is capable of developing resistance to commonly used antibiotics. Therefore, two or more antibiotics usually are given together with a PPI and/or bismuth containing compounds to eradicate the bacterium. (Bismuth and PPIs have anti-H. pylori effects.) Examples of combinations of medications that are effective are:

These combinations of medications can be expected to cure 70% to 90% of infections. However, studies have shown that resistance of H. pylori (failure of antibiotics to eradicate the bacterium) to clarithromycin is common among patients who have prior exposure to clarithromycin or other chemically similar macrolide antibiotics (such as erythromycin). Similarly, H. pylori resistance to metronidazole is common among patients who have had prior exposure to metronidazole. In these patients, doctors have to find other combinations of antibiotics to treat the H. pylori. Antibiotic resistance is another reason why antibiotics should be used carefully and judiciously for the right reasons, and indiscriminate use of antibiotics for improper reasons should be discouraged. First-line regimens for Helicobacter pylori eradication are taken from the guidelines developed by the American College of Gastroenterology as follows:

  1. Standard dose of a *PPI (proton pump inhibitor) *b.i.d. (esomeprazole is *q.d.), clarithromycin 500 mg b.i.d., amoxicillin 1,000 mg b.i.d. for 10-14 days
  2. Standard dose PPI b.i.d., clarithromycin 500 mg b.i.d. metronidazole 500 mg b.i.d. for 10-14 days
  3. 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. for 10-14 days
  4. PPI + amoxicillin 1 g b.i.d., for 5 days, followed by PPI, clarithromycin 500 mg, tinidazole 500 mg b.i.d. for 5 days (used mainly in other countries)

*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.

A recent investigation reported that triple therapy of either levofloxacin (Levaquin) or rifabutin in combination with amoxicillin and esomeprazole yielded cure rates of 90% and 88.6%. The treatments lasted 10 to 12 days respectively (10 days of levofloxacin 20=50 mg b.i.d. or rifabutin 150 mg q.d. for 12 days. Amoxicillin was 1 gm esomeprazole was 40 mg, both b.i.d.).

Some doctors may want to confirm eradication of H. pylori after treatment with a urea breath test or a stool antigen test, particularly if there have been serious complications of the infection such as perforation or bleeding in the stomach or duodenum. Endoscopic biopsies to determine eradication of the bacterium are not necessary, and blood tests are not good for determining eradication since it takes many months or years for the antibodies to H. pylori to decrease. The best tests for determining eradication are the breath and stool tests discussed previously. Patients who fail to eradicate H. pylori with treatment are retreated, often with a different combination of medications. Continue Reading

Reviewed on 10/20/2015
References
REFERENCES:

Cancer.gov. Helicobacter pylori and Cancer. Reviewed Sep 5, 2013
<http://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/h-pylori-fact-sheet>

Chey, W. et al. "American College Gastroenterology Guideline on the management of Helicobacter pylori Infection." Amer. J. Gastro, 102:1808-1825, 2007.
<http://s3.gi.org/physicians/guidelines/ManagementofHpylori.pdf>

FDA. FDA approves first Helicobacter pylori breath test for children. Feb 24, 2014
<http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm293278.htm>

Santacroce, L. "Helicobacter Pylori Infection." Medscape. Sep 11, 2014.
<http://emedicine.medscape.com/article/176938-overview>

Crowe, S. MD., et al. "Patient information: Helicobacter pylori infection and treatment (Beyond the Basics)." UpToDate. Oct 08, 2015.
<http://www.uptodate.com/contents/helicobacter-pylori-infection-and-treatment-beyond-the-basics>

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