Multiple regimens have been evaluated for Helicobacter pylori therapy in randomized controlled trials [1-5]. Despite the number of studies, the optimal therapeutic regimen has not yet been defined. The treatment regimen that is selected must be effective, but considerations such as cost, side effects, and ease of administration should also be taken into account. (See "Indications and diagnostic tests for Helicobacter pylori infection", section on 'When to test'.)
This topic review will discuss treatment regimens for H. pylori. The indications and diagnostic tests for H. pylori infection, as well as the bacteriology and epidemiology, are discussed elsewhere. (See "Indications and diagnostic tests for Helicobacter pylori infection" and "Bacteriology and epidemiology of Helicobacter pylori infection".)
Triple therapy with a proton pump inhibitor (PPI) should be used in areas where clarithromycin resistance is low (<15 percent). In the United States, given the limited information on antimicrobial resistance rates, we generally begin treatment with triple therapy with a PPI . However, in patients with recent or repeated exposure to clarithromycin or metronidazole or when clarithromycin resistance is high (≥15 percent), quadruple therapy should be used to treat H. pylori (table 1) [7-13].
Triple therapy — The regimen most commonly recommended for first line treatment of H. pylori is triple therapy with a PPI (lansoprazole 30 mg twice daily, omeprazole 20 mg twice daily, pantoprazole 40 mg twice daily, rabeprazole 20 mg twice daily, or esomeprazole 40 mg once daily), amoxicillin (1 g twice daily), and clarithromycin (500 mg twice daily) for 7 to 14 days. We suggest treatment for 10 days to two weeks.
A longer duration of treatment (14 versus 7 days) may be more effective in curing infection but this remains controversial [14-16]. A meta-analysis suggested that extension of PPI-based triple therapy from 7 to 14 days was associated with a 5 percent increase in eradication rates . Most studies included were based upon amoxicillin-based triple therapy.