triple therapy for Helicobacter pylori eradication

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Helicobacter pylori: triple therapy (1,2):

Eradication

First-line treatment in adults

  • offer people who test positive for H pylori a 7-day, twice-daily course of treatment with:
    • a PPI (see table in notes) and
    • amoxicillin 1g and
    • either clarithromycin 500mg or metronidazole 400mg

  • offer people who are allergic to penicillin a 7-day, twice-daily course of treatment with:
    • a PPI (see table in notes) and
    • clarithromycin 250mg and
    • metronidazole 400mg

  • offer people who are allergic to penicillin and who have had previous exposure to clarithromycin a 7-day, twice-daily course of treatment with:
    • a PPI (see table in notes) and
    • bismuth and
    • metronidazole 400mg and
    • tetracycline 500mg

Second-line treatment in adults

  • offer people who still have symptoms after first-line eradication treatment a 7-day, twice-daily course of treatment with:
    • a PPI (see table in notes) and
    • amoxicillin 1g bd and
    • either clarithromycin 500mg bd or metronidazole 400mg bd (whichever was not used first-line)

  • offer people who have had previous exposure to clarithromycin and metronidazole a 7-day, twice-daily course of treatment with:
    • a PPI (see table) and
    • amoxicillin 1g and
    • a quinolone or tetracycline 500mg

  • offer people who are allergic to penicillin (and who have not had previous exposure to a quinolone) a 7-day, twice-daily course of treatment with:
    • a PPI (see table) and
    • metronidazole 400mg and
    • levofloxacin 250mg

  • offer people who are allergic to penicillin and who have had previous exposure to a quinolone:
    • a PPI (see table) and
    • bismuth and
    • metronidazole 400mg and
    • tetracycline 500mg

Seek advice from a gastroenterologist if eradication of H pylori is not successful with second-line treatment

Notes (2):

  • there is evidence that the addition of bovine lactoferrin to triple therapy led to an increase in Helicobacter pylori eradication (3)
    • a more recent meta-analysis concluded that "...supplementation with probiotics could be effective in increasing eradication rates of anti-H. pylori therapy, and could be considered helpful for patients with eradication failure. Furthermore, probiotics show a positive impact on H. pylori therapy-related side effects.." (4)
  • quadruple therapy for H. pylori
    • a meta-analysis revealed that quadruple therapy appeared to be more effective than triple therapies for eradicating single-drug resistant H. pylori infection (5)
      • the study authors observed that resistance to metronidazole or clarithromycin could be overcome to a great extent with quadruple therapies given for 5 or more days, especially those containing metronidazole and clarithromycin concomitantly
  • PPI doses for H pylori eradication therapy (1)

    PPI Dose (twice daily)
    Esomeprazole 20mg
    Lansoprazole 30mg
    Omeprazole 20-40mg
    Pantoprazole 40mg
    Rabeprazole 20mg


  • use of quinaolones - See MHRA advice for restrictions and precautions for using fluoroquinolone antibiotics due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding coadministration with a corticosteroid (March 2019)

  • key points (6):
    • always test for H.pylori before giving antibiotics. Treat all positives, if known DU (duodenal ulcer), GU (gastric ulcer), or low-grade MALToma. NNT in non-ulcer dyspepsia: 14.4
    • do not offer eradication for GORD
    • do not use clarithromycin, metronidazole or quinolone if used in the past year for any infection
    • penicillin allergy:
      • use PPI PLUS clarithromycin PLUS metronidazole
      • if previous clarithromycin, use PPI PLUS bismuth salt PLUS metronidazole PLUS tetracycline hydrochloride
    • relapse and no penicillin allergy use PPI PLUS amoxicillin PLUS clarithromycin or metronidazole (whichever was not used first line)
    • relapse and previous metronidazole and clarithromycin: use PPI PLUS amoxicillin PLUS either tetracycline OR levofloxacin (if tetracycline not tolerated)
    • relapse and penicillin allergy (no exposure to quinolone): use PPI PLUS metronidazole PLUS levofloxacin
    • relapse and penicillin allergy (with exposure to quinolone): use PPI PLUS bismuth salt PLUS metronidazole PLUS tetracycline
    • retest for H. pylori:
      • post DU/GU, or relapse after second-line therapy, using Urea Breath Test or stool antigen tests, consider referral for endoscopy and culture

Reference:

Last edited 06/2021 and last reviewed 06/2021

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