What should be considered prior to treatment of Helicobacter pylori (H pylori) infection?

Updated: Jul 21, 2021
  • Author: Luigi Santacroce, MD; Chief Editor: BS Anand, MD  more...
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Answer

Selected 2021 American Gastroenterological Association (AGA) best practices

Antibiotic resistance is typically the cause of refractory H pylori infection (ie, persistent infection following attempted eradication therapy). [12] Try to ascertain potential contributing causes, such as inadequate adherence to therapy and insufficient gastric suppression.

Thoroughly review prior antibiotic exposures. [12] In the setting of any history of treatment with macrolides or fluoroquinolones, avoid clarithromycin- or levofloxacin-based regimens, respectively, owing to the greater possibility of resistance. However, consider amoxicillin, tetracycline, and rifabutin as subsequent therapies in refractory H pylori infection as resistance to these antibiotics is rare.

Adjunct therapies, including probiotics, have been proposed, but they are considered experimental as their benefits remain unproven for treating refractory H pylori infection. [12]

2020 World Society of Emergency Surgery (WSES) guidelines

Perforated and bleeding peptic ulcer clinical practice guidelines were released in January 2020 by the WSES. Indications for antimicrobial therapy and for H pylori testing in patients with bleeding peptic ulcer are as follows [16] :

  • Empirical antimicrobial therapy not recommended
  • H pylori testing in all patients
  • If positive for  H pylori, eradication therapy recommended
  • First-line eradication therapy: Standard triple therapy (ie, amoxicillin, clarithromycin, proton-pump inhibitor [PPI])
  • First-line therapy if high clarithromycin resistance detected: Ten-day sequential therapy with four drugs (ie, amoxicillin, clarithromycin, metronidazole, PPI)
  • Second-line therapy if first-line failed: Ten-day levofloxacin-amoxicillin triple therapy
  • Start standard triple therapy after 72-96 hours of intravenous PPI, for 14-day duration

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