Treatment of Helicobacter pylori in Special Patient Populations

Treatment of Helicobacter pylori in Special Patient Populations
Andrea Richard, PharmD, Anoka Metro Regional Treatment Center / Minnesota Direct Care and Treatment

Background: Helicobacter pylori infection is a common cause of gastritis, gastric and duodenal ulcers, and gastric cancer. Due to the morbidity associated with these infections, complete eradication of the bacteria is the goal of therapy. Treatment guidelines from the American College of Gastroenterology (ACG) include first-line and salvage regimens consisting of antibiotics and at least one antacid agent. A review of the new guidelines written by Nguyen et al discussed the current evidence for H. pylori treatment selection in special populations.

Evidence: A total of 29 studies and meta-analyses evaluating the safety and efficacy of various therapeutic regimens in specific patient populations were included in the review by Nguyen et al. Per the 2017 ACG guidelines on treatment of H. pylori infection, first-line therapy for the general population includes either clarithromycin triple therapy (clarithromycin, amoxicillin or metronidazole, and a proton pump inhibitor (PPI)), bismuth quadruple therapy (bismuth salt, PPI, tetracycline, and metronidazole or amoxicillin), or triple antibiotic therapy (clarithromycin, amoxicillin, metronidazole, and PPI). 

For patients with a confirmed penicillin allergy, ACG guidelines recommend clarithromycin triple therapy with metronidazole. For patients with recent macrolide exposure, bismuth quadruple therapy with metronidazole is preferred due to the risk of harboring clarithromycin-resistant H. pylori. If the patient has other contraindications or fails either first-line regimens, a second-line therapy containing levofloxacin has favorable eradication rates. 

For patients with, or at risk for developing, a prolonged QTc-interval, therapies containing clarithromycin or levofloxacin may not be preferred. In these situations, bismuth quadruple therapy is the recommended regimen. In patients who have failed or are unable to tolerate bismuth quadruple therapy, the second-line regimen of choice is amoxicillin dual therapy. 

In asymptomatic patients who are pregnant or breastfeeding, it is recommended to delay treatment until delivery or cessation of breastfeeding due to lack of safety data for any of the regimens. In symptomatic patients, such as those with hyperemesis gravidarum, a risk vs. benefit conversation with the patient must occur. If the decision to pursue treatment is made, clarithromycin triple therapy is recommended.

In elderly patients with an H. pylori infection, special attention must be made for potential drug-drug interactions, appropriate drug dosing, and adverse drug monitoring. The first-line treatment recommendations remain the same as for the general population. Additionally, both clarithromycin and levofloxacin require renal dose adjustments.

Discussion: Recommended therapy for the treatment of H. pylori infection widely varies depending on patient-specific factors. Due to the complexity of these regimens and the importance of complete infection eradication, providers must ensure careful consideration be made to ensure optimal tolerability, safety, and efficacy.


  1. Nguyen CT, Davis KA, Nisly SA, Li J. Treatment of Helicobacter pylori in Special Patient Populations. Pharmacotherapy. 2019 Oct;39(10):1012-1022.

  2. Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017 Feb;112(2):212-239.