H. pylori Infection Treatment Guideline

H. pylori Eradication H. PYLORI INFECTION TREATMENT GUIDELINE

H. PYLORI INFECTION TREATMENT GUIDELINE

						Is patient allergic to penicillin?
						No			Yes
						▼		▼
	• Bismuth quadruple • Levofloxacin triple • Levofloxacin sequential			◄	Yes¹	Does patient have previous macrolide exposure?	Does patient have previous macrolide exposure?			Yes¹	►	Bismuth quadruple
				◄		Does patient have previous macrolide exposure?	Does patient have previous macrolide exposure?				►	Bismuth quadruple
						No			No
						▼		▼
		Recommended • Bismuth quadruple • Concomitant • Clarithromycin triple with amoxicillin				Other options • Sequential • Hybrid • Levofloxacin triple • Levofloxacin sequential	• Clarithromycin triple with metronidazole • Bismuth quadruple




FIRST-LINE THERAPIES
Regimen			Drugs/Dosing										Duration (days)
RECOMMENDED
Clarithromycin triple²			PPI (standard or double dose twice daily) + clarithromycin (500mg twice daily) + amoxicillin (1g twice daily) OR metronidazole (500mg three times daily)										14
Bismuth quadruple³			PPI (standard dose twice daily) + bismuth subcitrate (120–300mg 4 times daily) or subsalicylate (300mg 4 times daily) + tetracycline (500mg 4 times daily) + metronidazole (250mg 4 times daily or 500mg 3–4 times daily)										10 –14
Concomitant⁴			PPI (standard dose twice daily) + clarithromycin (500mg twice daily) + amoxicillin (1g twice daily) + nitroimidazole⁵ (500mg twice daily)										10 –14
SUGGESTED
Sequential⁴			PPI (standard dose twice daily) + amoxicillin (1g twice daily) THEN										5 –7
			PPI + clarithromycin (500mg twice daily) + nitroimidazole⁵ (500mg twice daily)										5 –7
Hybrid⁴			PPI (standard dose twice daily) + amoxicillin (1g twice daily) THEN										7
			PPI + amoxicillin + clarithromycin (500mg twice daily) + nitroimidazole⁵ (500mg twice daily)										7
Levofloxacin triple⁴			PPI (standard dose twice daily) + levofloxacin (500mg daily) + amoxicillin (1g twice daily)										10 –14
Levofloxacin sequential⁴			PPI (standard or double dose twice daily) + amoxicillin (1g twice daily) THEN										5 –7
			PPI + levofloxacin (500mg daily) + nitroimidazole⁵ (500mg twice daily)										5 –7
LOAD⁴			Levofloxacin (250mg daily) + omeprazole (double dose daily) + nitazoxanide (500mg twice daily) + doxycycline (100mg daily)										7 –10
NOTES
Key: PPI = proton pump inhibitor; LOAD = levofloxacin + omeprazole + Alinia + doxycycline ¹ Includes patients in regions where clarithromycin resistance is known to be >15%. ² Several PPIs (eg, Prilosec, Nexium, Prevacid, Aciphex) in combination with clarithromycin and amoxicillin have achieved FDA approval. FDA-approved combination products include Omeclamox-Pak (omeprazole/amoxicillin/clarithromycin) and Prevpac (lansoprazole/amoxicillin/clarithromycin). PPI + clarithromycin + metronidazole is not an FDA-approved regimen. ³ Not an FDA-approved regimen if prescribed separately. Pylera (bismuth subcitrate/tetracycline/metronidazole) combined with omeprazole for 10 days is FDA-approved. ⁴ Not an FDA-approved regimen. ⁵ Metronidazole or tinidazole. For FDA-approved regimens, see drug monographs at www.eMPR.com or contact company for full drug labeling.
REFERENCES
Chey WD, Leontiadis GI, Howde CW, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol 2017; 112:212-238; doi:10.1038/ajg.2016.563; published online 10 January 2017. (Rev. 3/2018)

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