Unifying Concepts

Helicobacter pylori Infection in Peptic Ulcer Disease

Endoscopy is the gold standard for diagnosis of peptic ulcer disease. Apart from  exclusion of malignant disease, detection of H pylori infection with histology or rapid urease tests is essential to the subsequent treatment plan. 

The standard first-line therapies used to be regimens, consisting of a proton-pump inhibitor (PPI) and two antibiotics, such as clarithromycin plus amoxicillin or metronidazole given for 7−14 days (termed PPI-based triple therapy).

Most frequent regimens recommended for treatment of Helicobacter pylori infection in peptic ulcer disease

Drug combinations Regimen Duration
Triple therapy PPI plus amoxicillin* plus
Double dose† of PPI every 12 h
1000 mg amoxicillin every 12 h
500 mg clarithromycin every 12 h
14 days
concomitant therapy
PPI plus amoxicillin plus
clarithromycin plus
Standard dose of PPI every 12 h
1000 mg amoxicillin every 12 h
500 mg clarithromycin every 12 h
500 mg metronidazole every 12 h
14 days
quadruple therapy
PPI plus bismuth
subcitrate plus tetracycline
plus metronidazole
Standard dose of PPI every 12 h
120 mg bismuth subcitrate every
6 h
500 mg tetracycline every 6 h
500 mg metronidazole every 8 h
14 days
triple therapy‡
PPI plus amoxicillin plus
levofloxacin with or
without bismuth
Standard dose of PPI every 12 h
1000 mg amoxicillin every 12 h
500 mg levofloxacin every 24 h
240 mg bismuth every 12 h
14 days
Rifabutin-based triple
PPI plus amoxicillin plus
Standard dose of PPI every 12 h
1000 mg amoxicillin every 12 h
150 mg rifabutin every 12 h
10 days

Other regimens used in the treatment of Helicobacter pylori combine different antibiotics with similar results (eg, triple therapy could combine a proton pump inhibitor [PPI] plus amoxicillin plus metronidazole or PPI plus metronidazole plus clarithromycin). Sequential quadruple therapy consists of a 5-day dual therapy with a PPI and amoxicillin followed by a 5-day triple therapy with a PPI plus clarithromycin plus tinidazole or metronidazole.
Hybrid quadruple therapies combine 10–14 days of dual therapy with PPI and amoxicillin with 7 days of treatment with clarithromycin and metronidazole at the end (or start, for reverse therapy).
*Use metronidazole if patients have penicillin allergy. †Double doses: omeprazole 40 mg, lansoprazole 60 mg, rabeprazole 40 mg, esomeprazole 40 mg.
‡Used as rescue regimen; bismuth-based therapy can be added to these drugs (for fluoroquinolone-based quadruple therapy).
§To be used when at least three recommended options have failed and if H pylori susceptibility testing is not available.



  1. Lanas A, Chan FKL. Peptic ulcer disease. Lancet. 2017 Aug 5;390(10094):613-624. [Medline]
  2. Kempenich JW, Sirinek KR. Acid Peptic Disease. Surg Clin North Am. 2018 Oct;98(5):933-944. [Medline]
  3. Fallone CA, Chiba N, van Zanten SV, Fischbach L, Gisbert JP, Hunt RH, Jones NL, Render C, Leontiadis GI, Moayyedi P, Marshall JK. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology. 2016 Jul;151(1):51-69. [Medline]


Created Nov 05, 2018.

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