Around 50% of the world's population is infected with Helicobacter pylori, a spiral-shaped, gram-negative bacterium first discovered in the 1980s by Australian scientists Barry Marshall and Robin Warren. H. pylori infection is transmitted through fecal-oral, oral-oral, or gastro-oral routes and attaches to the gastric epithelium, causing cell damage. Diagnosis involves non-invasive tests like the urea breath test or endoscopic tests like rapid urease testing. Standard first-line treatment is a triple therapy of a proton pump inhibitor, clarithromycin, and amoxicillin or metronidazole, although antibiotic resistance requires alternative therapies like quadruple therapy

1. Sudipta Bera
2nd Year B.D.S
HIDSAR

2. Introduction
About 50% of world’s population and
above 70% of India’s population is
infected with Helicobacter pylori
which in many cases is linked to
gastric & peptic ulcer. It is also the
most common chronic bacterial
infection in the world.

3. History
Helicobacter pylori was
first discovered in the
1980s in the patients of
stomach ulcers &
gastritis by two
Australian scientists Dr
Barry Marshall and
Dr Robin Warren for
which they received
Noble prize in 2005.

4. Helicobacter pylori
 Gram-negative
 Spiral-shaped
 Microaerophilic
 Multiple unipolar
flagella.
 Urease positive

5. Routes of transmission
 Humans are major reservoir of H.pylori.
 Gastro oral route
 Feco oral route
 Oral oral route
 From inadequately disinfected endoscopic
devices through water.

6. Pathogenesis
•Neutralizing gastric acid
•Invades the mucin layer
•Attaches to the epithelial layer
•Causes cell apoptosis, necrosis

8. Diagnosis of Infection
Non Endoscopic Tests
 Serologic
 Urea Breath Test
 Stool Antigen Test
Endoscopic Tests
 Histology
 Rapid Urease Test
 Culture
 PCR Assay
A Silver Stain of Dr. Marshall’s stomach biopsy
taken 8 days after he drank a culture of H. pylori

9. Treatment
 Standard Triple therapy.
 Bismuth Quadruple therapy.
 Sequential therapy.
 Levofloxacin therapy.
 Culture guided therapy.
 Rescue therapy.

10. Standard Triple therapy
PPI
Rabeprazole
20mg/
Pantoprazole 40
mg/
Ranitidine
150mg
Clarithromycin
500mg
Metronidazole
500mg/
Amoxicilin
1g
For 14 days TWICE A DAY

11. Bismuth Quadruple therapy
PPI Twice a day
Metronidazole 250mg trice a day
Bismuth subsalicylate 525mg thrice a day
Tetracycline 500mg thrice a day

12. Sequential therapy
“five plus five” day therapy
• 1st five days PPI
Amoxicillin 1g
• 2nd five days
PPI, bid
Clarithromycin 500mg,bid
Metronidazole 500mg,bid

13. Levofloxacin-based triple therapy
second line therapy
For patients who had failed one or more
treatment.
 PPI, Standard dose, bid
 Amoxicillin 1g, bid
 Levofloxacin 250mg, bid – for 10 days
Region with high Clarithromycin & metronidazole resistance

14. H. pylori resistance to antibiotics
 Clarithromycin : Not overcome by increasing
all or none dose and duration.
 Levofloxacin : Not overcome by increasing
all or none dose and duration.
 Metronidazole : Overcome by increasing dose
not all or none and duration.
 Amoxicillin : Rare in most regions
 Tetracyclin : Rare in most regions
 Bismuth : Does not occur

15. Culture-guided therapy
Recommended third line therapy
PPI
Bismuth
1st antibiotic
2nd antibiotic
Standard dose, bid
525mg, qid
Selected by antimicrobial
sensitivity test
Selected by antimicrobial
sensitivity test
For 10-14 days

16. Rescue therapy
PPI High dose, bid
Amoxicillin 1g,bid
Rifabutin 150mg, bid
For 14 days
Although rifabutin is a antitubercular drug it is used
as last resort for patients with clarithromycin and
metronidazole resistance as it shows high efficacy
and no resistant strains with non hazardous side
effects.

17. Factors affecting treatment
 Poor compliance to therapy.
 Primary antibiotic resistance.
 Alcohol consumptions.
 Smoking.
 Reoccurrence from dormant forms.
 Gastric acid hypersecretion.
 CYP2C19 genetic polymorphism.
 High bacterial load.

18. Eradication Confirmation
Indicated in following situations;
1. Patients who have persistent symptoms after
H. pylori treatment for dyspepsia.
2. Patients who had an H. pylori associated ulcer.
3. Patients who had MALT lymphoma.
Eradication can be confirmed by
1. Urea breath test after 4 weeks of treatment.
2. Fecal antigen test after 4 weeks of treatment.
3. Endoscopy.

19. Side effects of treatment
Side effects are reported in around 30-40% of patients undergoing
treatment. Side effects are mild; fewer than 10% of patients stop
treatment due to side effects.
1. The most common side effect is a metallic taste due to
metronidazole or clarithromycin.
2. Metronidazole can cause peripheral neuropathy,
disulfiram-like reaction when taken with alcohol.
3. Clarithromycin can cause taste alteration, nausea,
vomiting, abdominal pain.
4. Tetracycline can induce photosensitivity reaction in
some cases.
5. Amoxicillin & Levofloxacin both causes diarrhea & skin
rash
6. Rifabutin in very few cases show myelotoxicity.

20. References
 Marshall BJ et al. MedJ Aust 1985;142 : 436-439
 Robbins basic pathology textbook :763-769
 Current topics in microbiology and immunology, C.A.M.Macnulty
 World J Gastroenterol. 2014 Sep 28; 20(36): 12781–12808
 World J Gastroenterol. 2014 May 14; 20(18): 5461–5473
 Pathogenesis of Helicobacter pylori Infection Johannes G. Kusters, Arnoud H.
M. van Vliet, Ernst J. Kuipers.
 Malfertheiner P et al. Gut 2012; 646-664
 Graham DY et al. Drugs 2008; 68: 725-736
 Gisbert JP et al. J Clin Gastroenterol 2010; 44 : 313-325
 Gibsert J P et al. Aliment Pharmacol Ther 2012 ; 35 : 209-221
 ACG 2019 internal medicine Bruce Jancin.
 Drug therapy for peptic ulcer Dr. Sukanta Sen.
 Microbiology Abigali A. Salyers, Dixie D White. Therap Adv Gastroenterol. 2009
Nov; 2(6): 317–322. Dino Vaira,corresponding author Angelo Zullo, Cesare Hassan,
Giulia Fiorini, and Nimish Vakil.