Treatment of Helicobacter pylori Infection(beta)
Official guideline of the American College of Gastroenterology.
Test if active PUD, history of PUD (unless known H. pylori test of cure), low-grade MALT lymphoma, or history of resected early gastric CA; if positive, then treat.
Noninvasive testing if age <60 + dyspepsia without alarm features (i.e., dysphagia, weight loss, GIB or anemia); if positive, then treat.
Test with gastric biopsy if functional dyspepsia and undergoing EGD; if positive, then treat (NNT = 14 for cure of functional dysplasia).
Do not test if typical GERD symptoms without PUD; if tested and positive, then offer to treat (effects on GERD symptoms unpredictable).
Consider testing if long-term, low-dose ASA use to reduce risk of GIB; if positive, then treat.
Test if starting chronic course of NSAIDs (unclear benefit if already on NSAIDs); if positive, then treat.
Test if unexplained iron deficiency anemia; if positive, then treat.
Consider previous antibiotic exposure(s) prior to treating H. pylori infection.
Treat with clarithromycin triple therapy (PPI BID + clarithromycin 500 mg/day + amoxicillin 1 g/day or metronidazole 500 mg TID) x 14 days (NNT = 12) where <15% H. pylori clarithromycin resistance and no history of macrolide exposure/PCN allergy.
Sequential therapy (PPI BID + amoxicillin 1 g BID x 5-7 days, then PPI BID + clarithromycin 500 mg BID + a nitroimidazole BID x 5-7 days) is a suggested 1st line option.
Hybrid therapy (concomitant + sequential) with PPI + amoxicillin x 7 days, then PPI + amoxicillin + clarithromycin + a nitroimidazole x 7 days is a suggested 1st line option.
Concomitant therapy (PPI BID + clarithromycin 500 mg BID + amoxicillin 1 g BID + a nitroimidazole) x 10-14 days is a 1st line option in North America.
If persistent H. pylori, avoid previously used antibiotic.
If clarithromycin based therapy previously used, recommend bismuth quadruple therapy or levofloxacin salvage regimens; best salvage therapy contingent on previous antibiotic exposure and local antibiotic resistance data.
If previously used bismuth quadruple therapy, recommend clarithromycin or levofloxacin based salvage regimens.
Salvage treatment options include: bismuth quadruple therapy x 14 days.
Salvage treatment options include: levofloxacin triple regimen x 14 days.
Concomitant therapy (see Recommended 1st line treatment) x 10–14 days.
How strong is the ACG's recommendation?