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Helicobacter Pylori Eradication

Updated H. pylori eradication therapy regimens including bismuth quadruple, concomitant, and rescue regimens based on Maastricht VI/Florence consensus.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Dahiliye (İç Hastalıkları) department. Book Appointment →

What is Helicobacter Pylori Eradication?

H. pylori epidemiology and pathogenesis: gram-negative microaerophilic spiral bacterium colonizing gastric mucosa; global prevalence 50% (higher in developing countries). Transmission - oral-oral, fecal-oral; mostly acquired in childhood. Virulence factors - urease (acid neutralization), CagA (cytotoxin associated gene A; pro-inflammatory), VacA (vacuolating cytotoxin), BabA (adhesin). Pathology spectrum - chronic gastritis (100%), peptic ulcer (10-15%), gastric adenocarcinoma (1-3%, especially intestinal type), MALT lymphoma (<1%, often regresses with eradication), iron deficiency anemia, ITP.

Diagnosis: 1) Non-invasive - urea breath test (sensitivity 95%, specificity 95%; first choice; PPI off ≥2 weeks, antibiotic off ≥4 weeks); stool antigen test (similar performance, cheaper); serology (low specificity, only suggests prior exposure, not active); 2) Invasive (endoscopy) - histology (sensitivity 90-95%; gold standard with H&E + Giemsa staining), rapid urease test (CLO test; 5-10% false negative if PPI), culture (allows susceptibility testing; needed in refractory cases), molecular tests (PCR, FISH for clarithromycin resistance). Indications - PUD, MALT lymphoma, gastric cancer first-degree relatives, atrophic gastritis, ITP, iron deficiency, long-term NSAID/aspirin, dyspepsia (test-and-treat <60 yr).

Eradication regimens (Maastricht VI/Florence 2022): 1) First-line - bismuth quadruple therapy (BQT): PPI bid + bismuth subcitrate 240 mg qid + tetracycline 500 mg qid + metronidazole 500 mg tid, 14 days (eradication >90%); preferred in high clarithromycin resistance (>15%); 2) Alternative first-line - concomitant therapy: PPI bid + amoxicillin 1 g bid + clarithromycin 500 mg bid + metronidazole 500 mg bid, 14 days; only if low clarithromycin resistance; 3) Rescue - levofloxacin triple (PPI + amoxicillin + levofloxacin 500 mg/day), rifabutin triple (PPI + amoxicillin + rifabutin 150 mg bid); high-dose dual therapy (HDDT) - PPI qid + amoxicillin 1 g qid; vonoprazan-based regimens (potassium-competitive acid blocker) increasing in availability. Confirmation - urea breath test or stool antigen ≥4 weeks after eradication, ≥2 weeks off PPI.

Symptoms

Epigastric pain, often nocturnal or fasting
Dyspepsia, bloating, early satiety
Nausea and vomiting
Iron deficiency anemia (refractory to oral iron)
Hematemesis or melena (peptic ulcer bleeding)
Asymptomatic in many infected individuals

Risk Factors

Lower socioeconomic status and crowded living
Childhood acquisition (most cases)
Family history of gastric cancer
Origin from high-prevalence region
Sharing of utensils and food
Prior gastric surgery (recurrent infection)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Persistent dyspepsia, especially with alarm symptoms
  • Peptic ulcer disease confirmed by endoscopy
  • MALT lymphoma diagnosis
  • Iron deficiency anemia without obvious cause
  • Family history of gastric cancer
  • Long-term NSAID or aspirin use planning

Treatment Methods

01
Bismuth quadruple therapy 14 days (first-line)
02
Concomitant therapy if low clarithromycin resistance
03
Levofloxacin or rifabutin rescue regimens
04
High-dose dual therapy (PPI + amoxicillin) alternative
05
Vonoprazan-based regimens (P-CAB) emerging
06
Confirm eradication 4 weeks after treatment

Which Department to Visit?

You can visit our Dahiliye (İç Hastalıkları) department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.