Helicobacter pylori infection

20 mg twice daily as the PPI component - of the quadruple regimen on line 1, and of the triple regimen on line 2 x 14 days

Specialist pediatric gastroenterology regimen only

Egyptian National Drug Formulary - Gastrointestinal Tract, bismuth subcitrate monograph, for the PPI of the bismuth quadruple: "One omeprazole 20mg capsule should be taken twice a day with a bismuth capsule after the morning and evening meal for 10 days." The 14-day course follows Helicobacter pylori Infection - disease-level clinical article (h-pylori-full.txt): "Commonly recommended regimens include 14-day bismuth quadruple therapy".

Proton pump inhibitor that raises intragastric pH, improving the stability and activity of the accompanying antibiotics and directly suppressing H. pylori; the acid-suppressing backbone of both the quadruple and triple eradication regimens.

Three capsules four times a day, after meals and at bedtime. Each capsule contains bismuth subcitrate potassium 140 mg, metronidazole 125 mg and tetracycline hydrochloride 125 mg. Give with omeprazole 20 mg twice daily. x 14 days

CONTRAINDICATED under 12 years old; not recommended between 12 and 18 - specialist use only in that band. The Egyptian National Drug Formulary's bismuth subcitrate monograph (Gastrointestinal Tract, 2025) sets out these age limits in its contraindications section.

Helicobacter pylori Infection - disease-level clinical article (h-pylori-full.txt), first-line treatment: "Current first-line treatment recommendations vary according to regional antibiotic resistance patterns. Commonly recommended regimens include 14-day bismuth quadruple therapy and concomitant (nonbismuth quadruple) therapy consisting of a proton pump inhibitor (PPI), amoxicillin, clarithromycin, and metronidazole." That is the source of the 14-day course. The Egyptian National Drug Formulary - Gastrointestinal Tract, bismuth subcitrate monograph, states the Egyptian combined capsule - "Capsule: 140 mg of bismuth subcitrate potassium, in combination with 125 mg of metronidazole, and 125 mg of tetracycline hydrochloride." - and a shorter licensed course for it: "Administer three capsules 4 times a day (after meals and at bedtime) for 10 days." with "One omeprazole 20mg capsule should be taken twice a day with a bismuth capsule after the morning and evening meal for 10 days". Both courses are stated so the guideline course and the licensed course are visible at the point of prescribing.

Bismuth quadruple therapy leads because it contains no clarithromycin. Both the Maastricht VI/Florence consensus (2022) and the American College of Gastroenterology reserve clarithromycin triple therapy for areas where resistance to it runs at 15% or below, and the Egyptian National Drug Formulary says to avoid clarithromycin-based regimens once local resistance reaches that level. Egypt's own clarithromycin resistance rate is not documented in the cited sources, and published Egyptian figures vary widely, so the regimen that avoids clarithromycin is the safer empirical choice.

20 mg twice daily as the PPI component of the triple regimen - the same drug and dose as in regimen A x 14 days

Specialist pediatric gastroenterology regimen only

Egyptian National Drug Formulary - Antimicrobial 2023, amoxicillin monograph, Helicobacter pylori eradication, for the shape and length of the clarithromycin triple regimen: "Different regimens containing Amoxicillin 1 g twice daily with different agents e.g clarithromycin 500 mg twice daily, a standard-dose or double-dose proton pump inhibitor, metronidazole or tinidazole 500 mg twice daily or levofloxacin 500 mg once daily. regimen is for 10 to 14 days." That monograph says "a standard-dose or double-dose proton pump inhibitor" and prints no figure for omeprazole itself; the 20 mg twice-daily figure is the one the same formulary states for omeprazole in its bismuth subcitrate monograph, quoted on the quadruple regimen.

The PPI is not optional and it is not left behind on regimen A. Clarithromycin and amoxicillin without acid suppression do not eradicate H. pylori.

500 mg BID combined with Omeprazole + Amoxicillin (Triple therapy) x 14 days

Specialist use only in children

WATCH group - carries resistance cost. Egyptian EML 2025.

Egyptian National Drug Formulary - Antimicrobial 2023, amoxicillin monograph. Dosage Regimen, Helicobacter pylori eradication, which names the regimen and the clarithromycin dose used in it: "Different regimens containing Amoxicillin 1 g twice daily with different agents e.g clarithromycin 500 mg twice daily, a standard-dose or double-dose proton pump inhibitor, metronidazole or tinidazole 500 mg twice daily or levofloxacin 500 mg once daily. regimen is for 10 to 14 days." The same monograph states under Other warnings/precautions: "Helicobacter pylori eradication: Short-term combination therapy (≤7 days) has been associated with a higher incidence of treatment failure. Current guidelines recommend 10 to 14 days of therapy (triple or quadruple) for eradication of H. pylori in pediatric and adult patients". The formulary permits 10 to 14 days. All H. pylori eradication regimens shown are given as a 14-day course.

Clarithromycin is second-line because empirical clarithromycin triple therapy is kept for areas with low clarithromycin resistance. The Maastricht VI/Florence consensus (2022) and the American College of Gastroenterology put that limit at 15% or below, and the Egyptian National Drug Formulary says to avoid clarithromycin-based therapy once local resistance reaches that level. Egypt's own rate is not documented in the cited sources, so susceptibility testing should decide, not assumption.

1000 mg BID combined with Omeprazole + Clarithromycin (Triple therapy) x 14 days

Specialist use only in children

Egyptian National Drug Formulary - Antimicrobial 2023 (amoxicillin monograph)

Beta-lactam antibiotic that inhibits bacterial cell-wall synthesis; used as one of the antibiotic components of triple therapy alongside the PPI and clarithromycin, or as high-dose dual therapy, to eradicate H. pylori.

500 mg twice daily, added to Regimen B's omeprazole + amoxicillin + clarithromycin to make the concomitant quadruple x 14 days

The ENDF states its H. pylori eradication regimen as an adult regimen; no paediatric figure is given with it, so none is carried here.

Egyptian National Drug Formulary - Antimicrobial 2023, amoxicillin monograph. Dosage Regimen, Helicobacter pylori eradication, which sets out the regimen and its metronidazole component: "Different regimens containing Amoxicillin 1 g twice daily with different agents e.g clarithromycin 500 mg twice daily, a standard-dose or double-dose proton pump inhibitor, metronidazole or tinidazole 500 mg twice daily or levofloxacin 500 mg once daily. regimen is for 10 to 14 days." The same monograph states under Other warnings/precautions: "Helicobacter pylori eradication: Short-term combination therapy (≤7 days) has been associated with a higher incidence of treatment failure. Current guidelines recommend 10 to 14 days of therapy (triple or quadruple) for eradication of H. pylori in pediatric and adult patients". The formulary permits 10 to 14 days. All H. pylori eradication regimens shown are given as a 14-day course.

The disease article gives concomitant non-bismuth quadruple therapy - PPI, amoxicillin, clarithromycin and metronidazole - as a first-line alternative. The card already carries the other three drugs of that regimen under Regimen B; metronidazole appears on it only inside the fixed bismuth combination, where it cannot be used this way.