HELICOBACTER PYLORI TREATMENT SUMMARY AND RECOMMENDATIONS

1. All patients with evidence of active infection with H. pylori  should be

offered treatment. The choice of initial antibiotic regimen to treat H.
pylori should be guided by the presence of risk factors for macrolide
resistance and the presence of a penicillin allergy. In patients with risk
factors for macrolide resistance, clarithromycin-based therapy should be
avoided (algorithm 1 and table 1). (See 'Approach to selecting an antibiotic
regimen' above.)
2. Risk factors for macrolide resistance include:
•Prior exposure to macrolide therapy for any reason.
•High local clarithromycin resistance rates ≥15 percent or eradication
rates with clarithromycin-based triple therapy ≤85 percent.
In the United States, given the limited information on antimicrobial
resistance rates, we generally assume clarithromycin resistance rates are
greater than 15 percent unless local resistance data indicate otherwise.
3. For initial therapy in patients without risk factors for macrolide resistance,
we suggest triple therapy with a proton pump inhibitor
(PPI), amoxicillin (1 g twice daily), and clarithromycin (500 mg twice daily)
for 14 days (Grade 2B). We suggest substitution of amoxicillin
with metronidazole only in penicillin-allergic individuals since
metronidazole resistance is common and can reduce the efficacy of
treatment (Grade 2B). (See 'Clarithromycin-based therapy' above.)
4. We suggest bismuth quadruple therapy as initial treatment in patients with
risk factors for macrolide resistance (algorithm 1 and table 1).
Quadruple therapy consists of a PPI, bismuth subsalicylate, and two
antibiotics (metronidazole and tetracycline) given four times daily for 14 days.
Alternatively, a commercially available combination capsule containing
bismuth subsalicylate, metronidazole, and tetracycline may be used in
conjunction with a PPI. (See 'Salvage therapy for persistent H. pylori
infection' above and 'Bismuth quadruple therapy' above.)
5. Tests to confirm eradication should be performed in all patients treated
for H. pylori.
Eradication may be confirmed by a urea breath test, fecal antigen test, or
upper endoscopy performed four weeks or more after completion of
antibiotic therapy. PPI therapy should be withheld for one to two weeks prior
to testing. (See 'Confirmation of eradication' above and "Indications and
diagnostic tests for Helicobacter pylori infection in adults", section on
'Diagnostic tests'.)
6. In patients with persistent H. pylori  infection, the choice of antibiotic
therapy should be guided by the patient's initial treatment regimen and the
presence of relevant antibiotic allergies (algorithm 2 and table 2). For patients
failing a course of H. pylori treatment, we suggest an alternate regimen using
a different combination of medications (Grade 2B). In
general, clarithromycin and antibiotics used previously should be avoided if
possible. (See 'Salvage therapy for persistent H. pylori infection' above.)
7. Culture with antibiotic sensitivity testing should be performed to guide
antibiotic treatment in patients who have failed two prior treatment
regimens. Compliance with medications should also be reinforced. We
reserve the use of rifabutin-containing regimens for patients with ≥3 prior
antibiotic failures. (See 'Salvage therapy for persistent H. pylori
infection' above.)