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

Answer

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]:

PPI (lansoprazole 30 mg BID) plus
Bismuth potassium citrate 220 mg BID plus
Tetracycline 500 mg QID or amoxicillin 1 g TID plus
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]

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

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

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