What are the ACG guidelines for the treatment of H pylori infection (HPI)?

Updated: Apr 26, 2021
  • Author: BS Anand, MD; Chief Editor: Philip O Katz, MD, FACP, FACG  more...
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Answer

The 2017 American College of Gastroenterology (ACG) guidelines indicate that selection of an HPI management regimen should take into account any previous antibiotic exposure(s). The ACG also includes the following therapeutic strategies for first-line treatment [33] :

  • 10-14 days of bismuth quadruple therapy (bismuth, proton pump inhibitor [PPI], tetracycline, and a nitroimidazole) (strong recommendation), particularly in those with previous macrolide exposure or are penicillin allergic

  • (Recommended option) 10-14 days of concomitant PPI, clarithromycin, amoxicillin, and a nitroimidazole (strong recommendation)

  • 14 days of clarithromycin triple therapy (clarithromycin, a PPI, and amoxicillin or metronidazole) should be reserved for patients with no previous history of macrolide exposure who live in regions where clarithromycin resistance among H pylori isolates is known to be low (< 15%) (conditional recommendation)

  • (Suggested option) 5-7 days of sequential therapy with a PPI and amoxicillin, followed by 5-7 days with clarithromycin, a PPI, and a nitroimidazole (conditional recommendation)

  • (Suggested option) 7 days of a hybrid therapy with a PPI and amoxicillin, followed by 7 days with a PPI, amoxicillin, clarithromycin, and a nitroimidazole (conditional recommendation)

  • (Suggested option) 10-14 days of levofloxacin triple therapy (levofloxacin, a PPI, and amoxicillin) (conditional recommendation)

  • (Suggested option) 5-7 days of fluoroquinolone sequential therapy (a PPI and amoxicillin), followed by 5-7 days of a PPI, fluoroquinolone, and nitroimidazole (conditional recommendation)

Salvage treatment if first-line therapy fails and HPI persists include the following options [33] :

  • Avoid previously used antibiotics, if feasible (strong recommendation)

  • Preferred for patients who previously received first-line clarithromycin regimens: Bismuth quadruple therapy or levofloxacin salvage regimens (conditional recommendation)

  • Preferred for patients who previously received first-line bismuth quadruple therapy: Clarithromycin or levofloxacin-containing salvage regimens (conditional recommendation)

Salvage treatment regimens include the following [33] :

  • (Recommended) Bismuth quadruple therapy or levofloxacin triple therapy for 14 days (strong recommendation)

  • Avoid clarithromycin triple therapy (conditional recommendation)

  • (Suggested) Concomitant therapy for 10-14 days (conditional recommendation

  • (Suggested) Rifabutin triple regimen (rifabutin, a PPI, and amoxicillin) for 10 days (conditional recommendation)

  • (Suggested) High-dose dual therapy (a PPI and amoxicillin) for 14 days (conditional recommendation)


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