Helicobacter pylori: A concise review of the latest treatments against an old foe

Wafa A. Aldhaleei; Michael B. Wallace; Dana M. Harris; Yan Bi

doi:10.3949/ccjm.91a.24031

Article Figures & Data

Tables

View popup

TABLE 1

Noninvasive and invasive testing methods for Helicobacter pylori

Testing method	Pros	Cons	Cost (approximate)	Sensitivity	Specificity
Invasive tests
Endoscopic biopsy	Allows direct visualization of H pylori infection Allows for histological evaluation	Discomfort and risk of complications	$$–$$$	95%–98%	95%–98%
Rapid urease test	Quick results (usually within minutes) Relatively low cost	False negatives can occur with recent proton pump inhibitor use or active bleeding	$–$$	90%–95%	95%–98%
H pylori culture	Allows for antibiotic susceptibility testing	Time-consuming and labor-intensive	$$–$$$	Variable^{^a}	Variable^{^a}
Molecular testing (gastric tissue)	High sensitivity and specificity Can detect resistance mutations	Requires specialized equipment and expertise	$$–$$$	90%–95%	90%–95%
Noninvasive tests
Stool antigen test	Easy to collect specimens	May yield false negatives if antigen levels are low	$–$$	90%–95%	90%–95%
Molecular testing (stool)	Easy to collect specimens High sensitivity and specificity	Requires specialized equipment and expertise	$$–$$$	Variable	Variable
Serology (blood test)	Easy to perform	Cannot distinguish current infection from past exposure False positives can occur	$–$$	80%–85%	80%–85%
Urea breath test	Well tolerated High sensitivity and specificity	Requires abstaining from certain medications (eg, antibiotics, proton pump inhibitors) before the test False positives can occur in the presence of urease-producing bacteria other than H pylori	$$–$$$	95%–98%	95%–98%
GastroPanel^{^b}	Provides comprehensive information on gastric health	Limited availability Interpretation may be complex	$$$	Variable	Variable

↵^a Depending on DNA extraction method.
↵^b Combination of immunoglobulin G serology coupled with pepsinogen I and II testing.
Based on information from references 8 and 9.

View popup

TABLE 2

Recommended susceptibility-based Helicobacter pylori eradication therapy after failure of empiric therapy

Susceptibility testing results	Recommended regimen
Clarithromycin-susceptible	Clarithromycin triple therapy for 14 days
Clarithromycin-resistant, metronidazole-susceptible	Metronidazole triple therapy for 14 days
Clarithromycin- and metronidazole-resistant, levofloxacin-susceptible	Preferred: empiric therapy with bismuth quadruple therapy for 14 days Alternative: levofloxacin triple therapy for 14 days^{^a}

↵^a If levofloxacin triple therapy is selected and fails, bismuth quadruple therapy is the next step.
Based on information from reference 15.

View popup

TABLE 3

Effective Helicobacter pylori regimens available in the United States

Regimen	Drug and dosing	Duration
Empiric therapy
Bismuth quadruple therapy	Bismuth subsalicylate 300 mg 4 times daily, 30 minutes before meals Tetracycline 500 mg 4 times daily, 30 minutes after meals Metronidazole 500 mg 4 times daily, 30 minutes after meals Proton pump inhibitor (standard dose) twice daily, 30 minutes before meals and at bedtime, or before morning and evening meals	14 days
Bismuth quadruple therapy (Pylera)	Combination pill containing bismuth, tetracycline, and metronidazole 4 times daily with meals and at bedtime Proton pump inhibitor (standard dose) twice daily, 30 minutes before meals and at bedtime	14 days
Susceptibility-based therapy
Clarithromycin triple therapy	Clarithromycin 500 mg twice daily, 30 minutes after meals Amoxicillin 1 g twice daily, 30 minutes after meals Proton pump inhibitor (standard dose) twice daily, 30 minutes before meals	14 days
Metronidazole triple therapy	Metronidazole 500 mg twice daily, 30 minutes after meals Amoxicillin 1 g twice daily, 30 minutes after meals Proton pump inhibitor (standard dose) 3 times daily, 30 minutes before meals	14 days
Levofloxacin triple therapy	Levofloxacin 500 mg daily, 30 minutes after meal Amoxicillin 1 g twice daily, 30 minutes after meals Proton pump inhibitor (standard dose) twice daily, 30 minutes before meals	14 days

Based on information from reference 15.

View popup

TABLE 4

Proposed approach for Helicobacter pylori eradication therapy incorporating vonoprazan

		Preferred regimens	Alternative regimens
Antimicrobial susceptibility information not available	Clarithromycin resistance < 15%	Vonoprazan triple therapy^{^a}	Vonoprazan dual therapy^{^b} Clarithromycin triple therapy Bismuth quadruple therapy
Antimicrobial susceptibility information not available	Clarithromycin resistance ≥ 15%	Bismuth quadruple therapy	Vonoprazan dual therapy^{^b}
Antimicrobial susceptibility information available	Clarithromycin susceptible	Clarithromycin or vonoprazan triple therapy^{^a}	Vonoprazan dual therapy^{^b}
	Metronidazole susceptible	Metronidazole triple therapy	Vonoprazan dual therapy^{^b}
	Levofloxacin susceptible	Levofloxacin triple therapy	Vonoprazan dual therapy^{^b} Bismuth quadruple therapy