Treatment for Helicobacter pylori infection

Which of the following is an acceptable treatment for Helicobacter pylori infection?

A) Bismuth, amoxicillin, metronidazole, and omeprazole
B) TMP-sulfamethoxazole, sucralfate, and metronidazole
C) Omeprazole, clindamycin, and sucralfate
D) Docusate, tetracycline, and metronidazole
E) Ranitidine, metronidazole, and ampicillin

Answer and Discussion

The answer is A. Bismuth, amoxicillin, metronidazole, and omeprazole

 Helicobacter pylori is a bacteria found in the stomach that is present in >80% of patients with duodenal ulcers and up to 60% of those with gastric ulcers. The incidence appears to increase with increasing age. Most H. pylori colonization is asymptomatic. Test sensitivity is reduced if the patient is taking Proton Pump Inhibitors (PPIs), bismuth or antibiotics.
Tests include urea breath testing. The patient ingests a urea solution with a carbon isotope and then breathes into a container; in the presence of H. pylori, urease hydrolyzes the urea to release labeled CO2, which can be detected by a mass spectrometer. A stool antigen enzyme immunoassay is reliable in confirming successful treatment, but should not be used to test for eradication of H. pylori until at least 4 weeks after completion of therapy. Serology antibody tests for H. pylori are useful in ruling out the diagnosis, but they lack specificity and are not reliable (because of persisting antibodies) for documenting eradication. The gold standard for diagnosis is biopsy and histologic examination

In large clinical trials, combinations of antimicrobial drugs have been successful in eradicating the organism in up to 90%, but in practice, eradication rates are lower due to increasing resistance to clarithromycin and metronidazole and poor patient adherence to the multidrug regimens.
Eradication rates with commonly prescribed triple therapy regimens have fallen below 80%. Quadruple therapy and sequential therapy have higher rates of eradication. A recent study found no difference between sequential therapy and quadruple therapy, with both achieving eradication rates of 92% to 93%. Quadruple therapy should be considered for initial treatment in areas with a high rate (>20%) of clarithromycin-resistant H. pylori.
Triple therapy includes clarithromyscin, plus amoxicillin or metronidiazole, plus a PPI.
Quadruple treatment includes bismuth subsalicylate (PeptoBismol), plus metronidiazole, plus tetracycline plus a PPI.
Patients should be tested for successful eradication of H. pylori and those still infected after treatment with two different regimens should receive salvage therapy with a different regimen, such as a PPI, amoxicillin, and levofloxacin (Levaquin and others), if needed