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Am Fam Physician. 2018 Jan
H. pylori Infection: ACG Updates Treatment Recommendations
Evidence-Based First-Line Treatment Strategies:
RECOMMENDED
1 Clarithromycin triple therapy consists of a PPI, clarithromycin (Biaxin), and amoxicillin or metronidazole (Flagyl) for 14 days. The effect of H. pylori resistance to clarithromycin is well documented. Clarithromycin should be avoided in locations where resistance is greater than 15% and in patients with any previous macrolide exposure.
2 Bismuth quadruple therapy consists of a PPI, bismuth, tetracycline, and a nitroimidazole for 10 to 14 days. It may be a particularly good option in patients with macrolide exposure or who are allergic to penicillin. Although metronidazole resistance impacts the effectiveness of this regimen, it is not nearly as profound as with clarithromycin triple therapy. Bismuth quadruple therapy should be strongly considered as first-line treatment where clarithromycin resistance is high or in patients with any previous macrolide exposure.
3 Concomitant therapy consists of a PPI, clarithromycin, amoxicillin, and a nitroimidazole (tinidazole [Tindamax] or metronidazole) for 10 to 14 days. This regimen is a promising option that has been shown in international studies to be at least as effective as clarithromycin triple therapy with similar tolerability. Limited data show that the effects of clarithromycin resistance with this regimen are less than with clarithromycin triple therapy. A duration of 10 to 14 days seems appropriate, although studies to assess whether extending therapy to 14 days improves eradication are ongoing.
When First-Line Therapy Fails, What Are the Options for Salvage Therapy?
Bismuth quadruple therapy (PPI, bismuth, tetracycline, metronidazole) for 14 days or levofloxacin triple therapy (PPI, levofloxacin, amoxicillin) for 14 days are the recommended salvage regimens. Other suggested regimens include concomitant therapy (PPI, clarithromycin, amoxicillin, nitroimidazole) for 10 to 14 days, rifabutin triple therapy (PPI, amoxicillin, and rifabutin) for 10 days, and high-dose dual therapy (PPI and amoxicillin) for 14 days. Clarithromycin triple therapy is not recommended for salvage therapy.
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