Treatment for Helicobacter pylori infection, an overview

The best treatment schedule for eradication of Helicobacter pylori in Iran is a type of quadruple therapy for a minimum duration of two weeks. Since, clarithromycin and furazolidone based quadruple regimen has the highest eradication rate, it can be considered as the first line therapy. Metronidazole based quadruple therapy may be used as an alternative choice of first line therapy. It is also important to note that furazolidone based regimens could induce side effects and are highly contraindicated in patients with G6PD deficiency. We recommend triple therapy with a proton pump inhibitor (PPI) (eg, lansoprazole 30mg twice daily, omeprazole 20mg twice daily, pantoprazole 40mg twice daily, rabeprazole 20mg twice daily, or esomeprazole 40mg once daily), amoxicillin (1g twice daily), and clarithromycin (500mg twice daily) for 10 days to two weeks. We suggest substitution of amoxicillin with metronidazole (500mg twice daily) only in penicillin-allergic individuals since metronidazole resistance is common and can reduce the efficacy of treatment. An initial attempt at eradicating H. pylori fails in as many as 20 percent of patients. For patients failing one course of H. pylori treatment, we suggest either an alternate regimen using a different combination of medications, or preferably quadruple therapy consisting of a PPI twice daily and bismuth-based triple therapy preferably given with meals and an evening snack for 14 days. For those failing two attempts at treatment, it is especially important to reinforce compliance with medications. Culture with antibiotic sensitivity testing can be done to guide subsequent treatments but generally we forgo culture in favor of "rescue" therapy. We suggest levofloxacin (250mg), amoxicillin (1g) and a PPI each given twice daily for two weeks. Alternative dosing regimens have also been suggested.