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    Treatment of Helicobacter pylori Infection (beta)

    Official guideline of the American College of Gastroenterology.

    Strength
    Factual
    Strong recommendation
    Conditional recommendation
    Not a formal recommendation
    Evidence
    High quality evidence
    Moderate quality evidence
    High for efficacy, low for age threshold
    Moderate, very low for duration
    Low quality evidence
    Very low quality evidence
    Not applicable
    See salvage treatment options

    Treatment

    Epidemiology
    1. H. pylori prevalence higher outside of North America → in North America, highest amongst African-Americans, Asian/Hispanic immigrants, and low-income households.
    Indications to test and treat
    1. Treat if active H. pylori infection.
    2. 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.
    3. Noninvasive testing if age <60 + dyspepsia without alarm features (i.e., dysphagia, weight loss, GIB or anemia); if positive, then treat.
    4. Test with gastric biopsy if functional dyspepsia and undergoing EGD; if positive, then treat (NNT = 14 for cure of functional dysplasia).
    5. Do not test if typical GERD symptoms without PUD; if tested and positive, then offer to treat (effects on GERD symptoms unpredictable).
    6. Consider testing if long-term, low-dose ASA use to reduce risk of GIB; if positive, then treat.
    7. Test if starting chronic course of NSAIDs (unclear benefit if already on NSAIDs); if positive, then treat.
    8. Test if unexplained iron deficiency anemia; if positive, then treat.
    9. Test if adult with ITP; if positive, then treat.
    Penicillin allergy testing
    1. If failed 1st line therapy and reports PCN allergy, consider allergy testing → can safely treat most with amoxicillin-containing salvage regimens.
    Recommended 1st line treatment
    1. Consider previous antibiotic exposure(s) prior to treating H. pylori infection.
    2. 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.
    3. Treat with bismuth quadruple therapy (PPI BID + bismuth subcitrate 120–300 mg/day + tetracycline 500 mg/day + a nitroimidazole [e.g. metronidazole 500 mg TID]) x 14 days if high clarithromycin resistance or hx of macrolide exposure/PCN allergy.
    Suggested 1st line treatment
    1. 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.
    2. 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.
    3. 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.
    4. Omeprazole 40 mg, rifabutin 50 mg, and amoxicillin 1000 mg TID X14 days.
    Treatment success - testing
    1. Test of cure = negative urea breath, fecal antigen, or biopsy-based test >4 weeks after antibiotic completion and >1 week after holding PPI.
    Successful eradication
    1. Successful H. pylori eradication is highly influenced by sensitivity to antibiotic regimen and adherence to multidrug regimen.
    Resistance - what is known
    1. H. pylori resistance info is scarce → clarithromycin ~16-30%, metronidazole ~20%, levofloxacin ~19-31% in North America.
    Resistance - testing
    1. H. pylori antibiotic susceptibility can be determined, but testing not widely available.
    Salvage therapy
    1. If persistent H. pylori, avoid previously used antibiotic.
    2. 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.
    3. If previously used bismuth quadruple therapy, recommend clarithromycin or levofloxacin based salvage regimens.
    4. Salvage treatment options include: bismuth quadruple therapy x 14 days.
    5. Salvage treatment options include: levofloxacin triple regimen x 14 days.
    6. Concomitant therapy (see Recommended 1st line treatment) x 10–14 days.
    7. Do not repeat clarithromycin triple therapy.
    8. Rifabutin triple regimen (PPI + amoxicillin + rifabutin 300 mg/day) x 10 days.
    What do the icons mean?  
    Research PaperChey WD, Leontiadis GI, Howden CW, Moss SF. Acg clinical guideline: treatment of helicobacter pylori infection. Am J Gastroenterol. 2017;112(2):212-239.