Helicobacter pylori infection
Chronic gastric infection with gram-negative H. pylori. Leading cause of peptic ulcer disease and gastric cancer. Eradication follows Maastricht VI consensus.
ICD-10 B98.08 drugs
Also known as: H. pylori
Drugs used for this condition
- AAmoxicillinSecond line · Penicillins with extended spectrumAmoxicillin is part of most eradication regimens, but it is no longer the empirical first line in Spain. Where clarithromycin resistance is above 15% or unknown (the Spanish situation), Maastricht VI/Florence 2022, ACG 2024 and the VI Spanish consensus 2026 give bismuth quadruple therapy as first line, without Amoxicillin: a proton pump inhibitor (PPI, for example Omeprazole) + bismuth + Tetracycline + Metronidazole, 10 days per the VI consensus; Maastricht VI allows concomitant therapy (PPI + Amoxicillin + Clarithromycin + Metronidazole) when bismuth is unavailable. In the V Spanish consensus 2021 concomitant therapy with Amoxicillin was a first-line option alongside bismuth; in the VI consensus 2026 only the bismuth regimen remains first line. After failure of the bismuth regimen the standard is PPI + Amoxicillin + Levofloxacin + bismuth. Triple therapy with PPI + Clarithromycin + Amoxicillin (1 g twice daily) is appropriate only with proven clarithromycin susceptibility or local resistance below 15%. Per ACG 2024, Amoxicillin-containing regimens are an alternative in patients without penicillin allergy; allergic patients receive bismuth quadruple therapy. Eradication is confirmed by a breath test at least 4 weeks after treatment. Per the label, Amoxicillin is contraindicated in penicillin allergy and after anaphylaxis to another beta-lactam; diarrhoea, rash and antibiotic-associated colitis can occur; avoid it if infectious mononucleosis is suspected. Interactions: Methotrexate (increased toxicity), oral anticoagulants (monitor prothrombin time), Allopurinol (more rash); in Clarithromycin-containing regimens the main interactions (statins, QT prolongation) come from Clarithromycin. In pregnancy Amoxicillin is used when benefit outweighs risk; Tetracycline from the bismuth regimen is contraindicated in pregnancy.
- AClarithromycinFirst line · Macrolide antibioticClarithromycin is part of first-line H. pylori eradication regimens in regions where clarithromycin resistance is below 15%. Maastricht VI/Florence 2022 recommends triple therapy PPI + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 14 days. When resistance exceeds 15%, the first-line regimen is switched to bismuth-containing quadruple therapy without clarithromycin. The Russian Ministry of Health clinical recommendation "Gastritis and duodenitis in adults" (ID 708, 2024) lists clarithromycin in first-line regimens where susceptibility is confirmed.
- AEsomeprazoleFirst line · Drugs for peptic ulcer and GORD. Proton pump inhibitorsEsomeprazole is one of the PPIs used in H. pylori eradication. Maastricht VI/Florence 2022 and ACG 2017 recommend triple or bismuth quadruple therapy for 14 days. Esomeprazole 40 mg twice daily within the regimen provides acid suppression that supports antibiotic activity and concentration stability in the stomach.
- AMetronidazoleFirst line · Imidazole derivatives (antiprotozoal / antibacterial)Component of Helicobacter pylori eradication regimens per Maastricht VI/Florence Consensus 2022. In bismuth quadruple therapy: metronidazole 250–500 mg three to four times daily with tetracycline, bismuth, and PPI. Efficacy decreases with metronidazole resistance (above 20 % of strains in Russia).
- AOmeprazoleFirst line · Proton pump inhibitorsA component of H. pylori eradication regimens per Maastricht VI/Florence Consensus 2022. In triple therapy: omeprazole 20 mg BID with amoxicillin and clarithromycin. In bismuth quadruple therapy: with tetracycline and metronidazole. Course duration 14 days. PPI is continued at least 4 more weeks after antibiotics for mucosal healing.
- CMastic gumAdd-on therapy · Over-the-counter botanical supplement, the resin of Pistacia lentiscus var. Chia (Chios mastic), cultivated on the island of Chios in Greece; marketed for functional dyspepsia and H. pyloriMastic gum in H. pylori is not a replacement for standard eradication therapy but a possible mild adjunct. A small RCT by Dabos (Phytomedicine 2010) in 52 patients with H. pylori without ulcer compared mastic 350 mg three times daily for 14 days with pantoprazole and triple therapy: mastic monotherapy eradicated H. pylori in about 30–35% versus 77% in the triple therapy arm. This is well below the standard. Maastricht VI 2022 and the Spanish AEG/SEPD 2022 consensus place quadruple bismuth therapy first-line (omeprazole + bismuth + tetracycline + metronidazole for 10–14 days) or clarithromycin-based therapy in low-resistance regions; the target eradication rate is above 90%. In Spain Maastricht VI 2022 recommends quadruple bismuth first-line because of high clarithromycin resistance. The Cochrane systematic review by Wang (2016) on herbal adjuvants in H. pylori shows that some preparations improve adherence and reduce antibiotic side effects but do not replace them. If mastic is considered alongside eradication therapy, discuss with a gastroenterologist – as a stand-alone way to «treat H. pylori without antibiotics» it does not work.
Marketing claims without evidence base
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
- CLactoferrinNot recommended · Bovine colostrum and human-milk glycoprotein supplement marketed as «immune modulator», «iron support» and «antiviral»Lactoferrin is proposed as an adjunct to standard Helicobacter pylori eradication (triple or quadruple therapy). The Zou meta-analysis (Helicobacter 2009) pooled 9 RCTs with 1343 patients: adding lactoferrin 200–400 mg/day to standard eradication raised eradication rates from 76% to 86%. The trials were small, heterogeneous and mostly from China and Italy. The Maastricht VI / Florence Consensus 2022 recommends regimen selection based on local resistance (bismuth quadruple therapy or levofloxacin-containing regimen); lactoferrin is not mentioned in the main recommendations. Adjuvant addition to a prescribed regimen is discussed with the treating gastroenterologist – it does not replace PPIs and antibiotics and is not justified as monotherapy. If lactoferrin was bought instead of prescribed eradication, discuss with a doctor; incomplete eradication with persistent symptoms and positive serology raises the risk of ulcer recurrence and MALT lymphoma.
- DDeglycyrrhizinated licorice (DGL)Not recommended · Over-the-counter botanical supplement, an extract of Glycyrrhiza glabra root with glycyrrhizin removed (to eliminate the mineralocorticoid effect); marketed for peptic ulcer, functional dyspepsia and H. pyloriDGL is marketed as a «natural alternative to antibiotics for H. pylori». It is not a replacement for eradication therapy. Small in vitro and pilot studies show mild antimicrobial action of licorice flavonoids against H. pylori, but DGL has no clinical RCTs with H. pylori eradication as an endpoint. Maastricht VI 2022 and the Spanish AEG/SEPD 2022 consensus place quadruple bismuth therapy first-line (omeprazole + bismuth + tetracycline + metronidazole for 10–14 days) or clarithromycin-based therapy in low-resistance regions; eradication without antibiotics is not achieved at current evidence levels. The Cochrane systematic review by Wang (2016) on adjuvant herbal preparations in H. pylori shows that some herbs improve adherence and tolerance but do not replace antibiotics. If DGL was bought «instead of quadruple therapy for H. pylori», discuss the treatment plan with a gastroenterologist – untreated H. pylori infection leads to atrophic gastritis, ulcer disease and raised gastric cancer risk.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit