I am so sad

[Alehax]

I think I got this h.pylori from my husband. He had it in 2014 and got treated with IPP amoxicillin and clarithromicyn and then he had another flare up in 2016 and did an endoscopy and he was positive again and was given the same treatment. We are together since 2017 and he told me that he was negative (but actually he didn’t follow with a test after the therapy). He still had reflux from now and then, and stomach pain but he did’t think to investigate any further and I taught that he’s negative because he told me so.

I was treated with Augmentin in the beginning of October 2025 for a UTI and then 3 weeks after, I started to have acid reflux and it took a while until I figure out what was causing it.
(In January 2023 I took a helicobacter test for prevention because my cat was positive and I was negative…so it must be a new infection)

I took this therapy :
Esomeprasol 40 mg twice daily
Amoxicillin 1000 mg twice daily
Clarithromicyn 500 mg twice daily
Bismuth tripotassium dicitrate 120 mg 4 times a day

For 14 days and continued with esomeprasol 40 mg in the morning another 12 days
I don’t know if I lowered my chances of eradication with the 2nd line if I used bismuth in this one. And because I used claritromicyn if I my helicobacter transformed into a superbacteria.

And it’s 18 days since I finished the treatment so I can’t retest yet. But I live in Eastern Europe and I saw in the 2022 guidelines that you should not prescribe clarithromicyn to anyone unless you’ve tested before and it’s sensitive, but the doctor prescribed it to me even though the resistance is high.
I still have acid reflux and my tongue is still yellow, and I feel constant hunger.

Next week I can go and test, but I am sure it will be positive.
I want to do an endoscopy with culture but the hospital where I talked are only testing for amoxicillin tetracycline metronidazole and claritimicyn, I don’t know if it’s enough and look further. Do I need to ask for measuring the gastric pH during the endoscopy? I am not sure what therapy I can take next. If helicobacter is still sensitive to amoxicillin and bismuth. I don’t know if the next one should be with amoxicillin + levofloxacine, tetracycline and metronidazole, or amoxicillin and rifabutin and if I should change the PPI.
I really want this helicobacter to be gone the next round. I am already sad that I didn’t took the tetracycline meronidazole and bismuth in the first place.

My husband did this time ( 3rd) :

esomeprasol 40 twice daily
tetracycline 500 mg 4 times a day
metronidazole 500 mg 3 times a day
bismuth 240 twice a day
(All taken as individual pills since we don’t have Pylera in Romania). And he needs to retest in 2 weeks.

Is there a difference between taking Pylera vs separate pills in terms of eradication rate?

Do you think esomeprasol is good enough to be used next time ?
Using amoxicilline turns bacteria into cocoid form that resist to other antibiotics making it more difficult to treat?

[Helico_expert]

First, the good news is that your recent treatment confirms you are not allergic to amoxicillin. Amoxicillin is a highly effective antibiotic for H. pylori because the bacteria rarely develop resistance to it, and the same holds for bismuth. Consequently, both can be used effectively in subsequent treatment rounds if necessary. Regarding your concerns about "superbacteria" and the coccoid form of H. pylori, please be assured that using amoxicillin does not make the bacteria more difficult to treat later. While the bacteria can transition to a coccoid form under stress, this does not lead to the type of permanent resistance seen with other antibiotics, such as clarithromycin.

The success of treatment depends heavily on effective acid suppression, yet everyone metabolises Proton Pump Inhibitors (PPIs) differently. We often prefer rabeprazole (20mg three times a day) because most people have a low metabolic rate for it, meaning the acid suppression lasts longer and boosts the success rate. However, the most potent acid blockers currently available are P-CABs, such as vonoprazan. If your doctor has access to vonoprazan, it generally provides the best treatment outcomes. You do not necessarily need to measure gastric pH during an endoscopy, but switching to a more stable PPI or a P-CAB in the next round would be advisable.

Since there is a chance you contracted the strain from your husband, it is possible you share the same resistance profile. Therefore, Barry and I think it is logical for you to follow the same treatment regimen he is currently using. The PBTM (PPI, Bismuth, Tetracycline, and Metronidazole) protocol you mentioned is an excellent, robust treatment. Regarding your question on Pylera versus separate pills, there is no significant difference in eradication rates as long as the dosages are correct and the schedule is strictly followed. The separate pills are just as effective as the combination capsule.

For your next steps, both you and your husband must undergo a follow-up breath test to confirm the treatment was successful. To ensure an accurate result, you must be off all antibiotics and PPIs for at least four weeks. The culture tests you mentioned, testing for amoxicillin, tetracycline, metronidazole, and clarithromycin, are sufficient for tailoring a second-line therapy. Please do not be discouraged by the first round; with the right combination of acid suppression and effective antibiotics like tetracycline, the success rate remains very high.

[Alehax]

Thank you for your fast reply. Why is it written in the European guidelines : do not give clarithromicyn unless you tested and it’s supceptible ? Just because of unnecessary use of antibiotics ?

We will wait to be tested in 2/3 weeks and I will update here.

Did you have a patients given my bismuth add on triple therapy and then bismuth tetracycline and metronidazole and heal ?

And is there a specific time when to start the second treatment?

[Helico_expert]

The restricted use of Clarithromycin in Europe is likely due to high resistance rates. As this antibiotic was frequently prescribed for respiratory infections, particularly during the COVID-19 pandemic, many individuals now carry Clarithromycin-resistant H. pylori strains.

Bismuth itself possesses antimicrobial properties and has a 10% to 20% chance of eradicating the infection as a monotherapy. When used in a Clarithromycin-based triple therapy, the cure rate is approximately 60% to 70%. Subsequently, a regimen like Pylera offers an 80% to 90% success rate for those who did not clear the infection during the initial treatment. Overall, the cumulative success rate should be high.

There are no formal guidelines regarding the exact timing for starting a second treatment. If you did not experience significant adverse side effects from the first course, you may begin the second immediately. Alternatively, you can wait a week or two until you feel ready to proceed.