What are the rescue or third-line therapies for the eradication of Helicobacter pylori infection?

Updated: Dec 09, 2020
  • Author: Joseph Adrian L Buensalido, MD; more...
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Send ulcer biopsy specimen for antimicrobial culture and susceptibility before treatment. [3, 40, 4]   It is essential to avoid antimicrobials that have previously been used.  The preferred treatment for patients who have received a clarithromycin-containing first-line regimen are bismuth quadruple therapy or levofloxacin-salvage combination therapy.  In general, clarithromycin triple therapy is not recommended for salvage treatment.  [2]

Bismuth-based quadruple therapy (with amoxicillin, tetracycline, furazolidone, or metronidazole) is used for 14 days and comprises the following (eradication rates for all combinations below were above 90%) [41] :

  1. PPI (lansoprazole 30 mg BID) plus

  2. Bismuth potassium citrate 220 mg BID plus

  3. Tetracycline 500 mg QID or amoxicillin 1 g TID plus

  4. Furazolidone 100 mg TID or tetracycline 500 mg QID (if not already selected) or metronidazole 400 mg QID

For patients who already received bismuth quadruple therapy as first-line treatment, clarithromycin or levofloxacin-containing salvage regimens are preferred. [2]

Levofloxacin-based sequential therapy is superior to clarithromycin- and tetracycline-based therapies and consists of the following (eradication rates of up to 92.2%, as long as the H pylori was susceptible to levofloxacin): [16]

  1. PPI (esomeprazole 40 mg BID) + amoxicillin (1 g BID) for 7 days, then

  2. PPI (esomeprazole 40 mg BID) + metronidazole (500 mg BID) + levofloxacin (250 mg or 500 mg BID, with the former surprisingly achieving higher cure rates [12] ) for another 7 days

Other salvage regimens that can be recommended are the following [2] :

  1. Triple therapy (which includes levofloxacin) is also a recommended salvage regimen (see above)
  2. Concomitant therapy as described above
  3. 10-day rifabutin triple salvage regimen (PPI plus amoxicillin plus rifabutin) 
  4. High-dose dual therapy (PPI plus amoxicillin for 14 days) 

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