Treatment of Helicobacter pylori infection: a clinical practice update

Minerva Med. 2021 Apr;112(2):281-287. doi: 10.23736/S0026-4806.20.06810-X. Epub 2020 Jul 22.


Helicobacter pylori infection still represents a major health issue, especially in developing countries, with an estimate of 4 billion of infected subjects in 2015. The increase of antibiotic resistance has undermined the efficacy of standard triple therapy leading to more complex regimens. This review summarizes recommendations of international guidelines and reports the most recent evidence from meta-analyses and clinical trials on the treatment of Helicobacter pylori infection. The choice of H. pylori eradication regimen should be based on the local prevalence of clarithromycin resistance and the previous use of macrolides. Quadruple therapies (bismuth quadruple and concomitant) are the recommended regimens for the first-line treatment; a 14-day clarithromycin-containing triple therapy is suggested in areas with low prevalence of clarithromycin resistance and in patients without previous use of macrolides. Data on the efficacy of sequential therapy against clarithromycin resistant H. pylori strains are contradictory, and its use in the treatment of H. pylori infection is generally discouraged. Second-line treatments include levofloxacin-containing triple therapy and bismuth quadruple therapy. Probiotic supplementation should be used with the aim to reduce antibiotic-related adverse events. Recent evidence would support current guideline recommendations for the treatment of Helicobacter pylori infection.

Publication types

  • Review

MeSH terms

  • Antacids / therapeutic use*
  • Anti-Bacterial Agents / therapeutic use*
  • Bismuth / therapeutic use
  • Clarithromycin / therapeutic use
  • Drug Resistance, Bacterial
  • Drug Therapy, Combination / methods
  • Helicobacter Infections / drug therapy*
  • Helicobacter pylori / drug effects*
  • Humans
  • Levofloxacin / therapeutic use
  • Macrolides / therapeutic use
  • Meta-Analysis as Topic
  • Practice Guidelines as Topic
  • Probiotics / administration & dosage
  • Proton Pump Inhibitors / therapeutic use
  • Salvage Therapy / methods
  • Systematic Reviews as Topic


  • Antacids
  • Anti-Bacterial Agents
  • Macrolides
  • Proton Pump Inhibitors
  • Levofloxacin
  • Clarithromycin
  • Bismuth