eMedicine Specialties > Gastroenterology > Stomach

Helicobacter Pylori Infection: Treatment & Medication

Author: Luigi Santacroce, MD, Assistant Professor, Medical School, State University at Bari, Italy
Coauthor(s): Giuseppe Miragliotta, MD, Chairman, Professor, Department of Microbiology, University of Bari, Italy; Manoop S Bhutani, MD, FACG, FACP, Professor, Department of Medicine, Division of Gastroenterology, Director, Center for Endoscopic Ultrasound, Co-Director, Center for Endoscopic Research, Training and Innovation, University of Texas Medical Branch at Galveston
Contributor Information and Disclosures

Updated: Aug 14, 2008

Treatment

Medical Care

Only treat patients who have a test result positive for H pylori infection. Carefully educate patients regarding the importance of completing the prescription and about the potential adverse effects of the medication. Importantly, consider possible antibiotic resistance when selecting the treatment regimen.

  • The US Food and Drug Administration has approved some regimens, which are now accepted internationally, for the treatment of H pylori infection in patients with peptic ulcer disease, both gastric and duodenal.  
    • These regimens are also known as triple therapies and have reported cure rates from 85-90%.
    • Administer triple therapies for 10-14 days. The treatment regimens are omeprazole, amoxicillin, and clarithromycin (OAC) for 10 days; bismuth subsalicylate, metronidazole, and tetracycline (BMT) for 14 days; and lansoprazole, amoxicillin, and clarithromycin (LAC), which has been approved for either 10 days or 14 days of treatment.
    • Macrolide resistance in patients with H pylori infection is an important problem. Although the molecular mechanisms of nitroimidazole resistance are very complex and still unclear, resistance has been shown to be due to a single point mutation (usually in the RDXA gene, although other genes may be involved, eg, FRDXA) in 1 of 4 positions of the bacterial 23S rDNA. Such mutations also determine cross-resistance to other macrolides.
    • An emerging and increasing problem in many Western countries is the fact that some H pylori strains in children are resistant to the antibiotic clarithromycin. The causes are not known.
  • All the eradication treatments have a high incidence of certain adverse effects (eg, nausea, metallic taste). If skin rash, vomiting, or diarrhea occurs, discontinue treatment.
  • The links between H pylori and nonulcer dyspepsia are debated; however, some patients with nonulcer dyspepsia benefit from eradication. Patients with symptoms have a higher eradication rate than patients with nonulcer dyspepsia disease. Eradication of H pylori in patients without peptic ulcer disease has resolved the dyspepsia in a few cases.
  • See related CME at American College of Gastroenterology Issues Guidelines for Treatment of Helicobacter pylori Infection.

Surgical Care

Surgery is not required for patients with H pylori infection, but it may be considered in patients with severe complications, such as cancer.

Diet

No dietary restrictions are usually needed.

Activity

No limitations of physical activity are needed if patients do not have complications.

Medication

The goals of pharmacotherapy are to eradicate the microorganism, to prevent complications, and to reduce morbidity. Triple therapies are used. Worldwide, accepted treatment regimens are BMT, LAC, and OAC. BMT regimen is based on the administration of bismuth subsalicylate, metronidazole, and tetracycline. Add an H2-receptor antagonist for an additional 4 weeks. LAC regimen is based on the administration of lansoprazole, amoxicillin, and clarithromycin. OAC regimen is based on the administration of omeprazole, amoxicillin, and clarithromycin.

Antidiarrheals

The approved antidiarrheal for this infection is bismuth subsalicylate. It has both antisecretory and antimicrobial activity.


Bismuth subsalicylate (Bismatrol, Pepto-Bismol)

Has cytoprotective effect on GI mucosa, probably due to stimulation of prostaglandin production and modulation of immune response. In addition, has been demonstrated that some deposits (probably bismuth salts) appear on both surfaces of the cell wall of H pylori after <1 h. Such deposits induce distortion and vacuolization of the bacterial cell and loss of adherence of H pylori from antral epithelium.

Adult

525 mg PO qid; not to exceed 4.2 g/d

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Trivalent cation and may form insoluble complexes with quinolones and tetracyclines; decreases effects of tetracyclines and uricosurics; may be potentiated by sulfinpyrazone or probenecid; coadministration with anticoagulants may increase risk of bleeding; may increase toxicity of aspirin and hypoglycemics

Documented hypersensitivity; coagulopathy

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Category D in third trimester of pregnancy; may cause temporary and harmless darkening of tongue and/or black stool; alcohol consumption may cause abdominal cramps, nausea, and vomiting; caution in breastfeeding

Antibiotics

Use agents known to be effective against H pylori.


Metronidazole (Flagyl)

Reduced to its active form intracellularly only by anaerobic organisms, then disrupts helical structure of DNA and inhibits bacterial nucleic acid synthesis.

Adult

250-500 mg PO qid

Pediatric

Not established

Cimetidine may increase toxicity; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol

Documented hypersensitivity; bone marrow suppression

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in cardiac disease because of sodium content; caution in breastfeeding; adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy


Tetracycline (Sumycin)

Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s).

Adult

500 mg PO qid

Pediatric

<8 years: Not recommended
>8 years: Not established

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; can increase hypoprothrombinemic effects of anticoagulants; cholestyramine and colestipol have been shown to reduce tetracycline absorption

Documented hypersensitivity; severe hepatic dysfunction

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; also may increase photosensitizing effects of aminolevulinic acid, methoxsalen, and vitamin A analogs; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines


Clarithromycin (Biaxin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Adult

500 mg PO q12h

Pediatric

<20 months: Not recommended
>20 months: Not established

Toxicity increases with coadministration of fluconazole and pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; serious cardiac arrhythmias may occur with coadministration of cisapride; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents; may decrease efficacy of oral contraceptives

Documented hypersensitivity; coadministration with pimozide or cisapride

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Coadministration with ranitidine or bismuth citrate not recommended with CrCl <25 mL/min; administer half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies


Amoxicillin (Amoxil, Trimox)

Inhibits final stage of bacterial cell wall synthesis due to binding to specific PBPs on inner part of bacterial wall, leading to bacterial lysis.

Adult

1 g PO bid

Pediatric

Not established

Reduces efficacy of oral contraceptives; concomitant administration can reduce bioavailability of amoxicillin

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; high incidence of drug-related rashes reported in infants and patients with leukemias, viral infections, and allergies or atopic conditions

Proton pump inhibitors

Bind to proton pump of parietal cell, inhibiting secretion of hydrogen ions into gastric lumen. Relieve pain and heal peptic ulcers more rapidly than H2 antagonists.


Lansoprazole (Prevacid)

Works by inhibiting the H+/K+ -ATPase enzyme system of gastric parietal cells.

Adult

30 mg PO bid

Pediatric

Not established

May decrease effects of ketoconazole, itraconazole, iron salts, and ampicillin; may increase theophylline clearance

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Consider adjusting dose in liver impairment; not recommended during breastfeeding


Omeprazole (Prilosec)

Decreases gastric acid secretion by inhibiting parietal cell H+/K+ -ATP pump.

Adult

20 mg PO bid

Pediatric

Not established

May decrease effects of ketoconazole, itraconazole, iron salts, and ampicillin; may increase theophylline clearance; may affect absorption of cyanocobalamin

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Bioavailability may increase in elderly; not recommended during breastfeeding

H2 receptor blockers

Reversible competitive blockers of histamine at H2 receptors, particularly those in gastric parietal cells, wherein they inhibit acid secretion. H2 antagonists are highly selective, do not affect the H1 receptors, and are not anticholinergic agents. Proton pump inhibitors are usually preferred.


Ranitidine (Zantac)

Reduces basal and nocturnal gastric acid secretion by competitive inhibition of binding of histamine to receptors (H2 receptor) on gastric parietal cells. Although not effective as single agents for the eradication of H pylori, appears to increase systemic absorption of bismuth subsalicylate.

Adult

150 mg PO bid or 300 mg PO hs

Pediatric

Not established

May decrease effects of ketoconazole and itraconazole; may alter serum levels of ferrous sulfate, diazepam, cefuroxime, warfarin, some oral sulfonylureas, nondepolarizing muscle relaxants, and oxaprozin; can decrease renal clearance of metformin

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal or liver impairment; if changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment; may worsen acute porphyria or phenylketonuria


Famotidine (Pepcid)

Competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen ion concentrations.

Adult

40 mg/d PO bid

Pediatric

Not established

May decrease effects of ketoconazole and itraconazole

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

If changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment

More on Helicobacter Pylori Infection

Overview: Helicobacter Pylori Infection
Differential Diagnoses & Workup: Helicobacter Pylori Infection
Treatment & Medication: Helicobacter Pylori Infection
Follow-up: Helicobacter Pylori Infection
Multimedia: Helicobacter Pylori Infection
References
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Further Reading

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Keywords

Helicobacter pylori infection, H pylori infection , Helicobacter pylori, H pylori, peptic ulcer disease, gastric cancer, gastric lymphoma, gastritis, gastric ulcers, PUD, Campylobacter pylori, C pylori, extragastric disease, mucosa-associated lymphoid tissue lymphomas, MALTomas, coronaritis, gastroesophageal reflux disease, GERD, iron deficiency anemia, iron-deficiency anemia, gastrointestinal disease, GI disease, heartburn, acid reflux, sour stomach, acid stomach, coronaritis, gastric mucosal cell proliferation, mucous cell proliferation, adenocarcinoma, ulcer, chronic active gastritis, Hp, Hp infection, HP infection

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Contributor Information and Disclosures

Author

Luigi Santacroce, MD, Assistant Professor, Medical School, State University at Bari, Italy
Disclosure: Nothing to disclose.

Coauthor(s)

Giuseppe Miragliotta, MD, Chairman, Professor, Department of Microbiology, University of Bari, Italy
Disclosure: Nothing to disclose.

Manoop S Bhutani, MD, FACG, FACP, Professor, Department of Medicine, Division of Gastroenterology, Director, Center for Endoscopic Ultrasound, Co-Director, Center for Endoscopic Research, Training and Innovation, University of Texas Medical Branch at Galveston
Manoop S Bhutani, MD, FACG, FACP is a member of the following medical societies: American Association for the Advancement of Science, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Institute of Ultrasound in Medicine, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Medical Editor

David Greenwald, MD, Fellowship Program Director, Associate Professor, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine
David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Oscar S Brann, MD, FACP, Associate Clinical Professor, Department of Medicine, University of California at San Diego; Consulting Staff, Mecklenburg Medical Group
Oscar S Brann, MD, FACP is a member of the following medical societies: American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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