-
Adult | Awaiting initial tx
No hx of macrolide exposure and local clarithromycin resistance low (<15%) Treat x10-14 days, depending on abx regimen;1-3 test success of H. pylori eradication tx. - Treat x14 days for all regimens (per ACG and Toronto);1,2 14 days unless shorter/10-day tx proven effective locally (per Maastricht/Florence).3
- Ask about previous abx exposure to help determine 1st-line tx;1 consider regional abx resistance patterns (when avail.)1-3 and eradication rates when choosing 1st-line tx;2 clarithro susceptibility testing, if avail. through molecular techniques or cx, is recommended before prescribing any clarithro-containing tx,3 but these tests not widely avail. in the U.S.
- Test success of eradication tx: Use urea breath test, fecal antigen test, or bx at least 4wk after tx completion and after withholding PPI tx for 1-2wk.1,3
Footnotes 1 ACG 2024.
Recommended Tx
• Bismuth quadruple tx x14 days.
Suggested Tx
• Rifabutin triple tx x14 days.
• PCAB dual tx x14 days.
• PCAB triple tx x14 days.
Not Recommended
• Concomitant tx x10-14 days.
• PPI-clarithro triple tx x14 days.
• Sequential tx x5-7 days.
• Hybrid tx x7 days, then x7 days.
• Levofloxacin triple tx x10-14 days.
• Fluoroquinolone sequential tx x5-7 days.
• LOAD x7-10 days.
Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep;119(9):1730-1753. Full-text article
2 Toronto Consensus 2016.
Recommended Tx
• Bismuth quadruple tx x14 days.
• Concomitant nonbismuth quadruple tx x14 days.
• PPI triple tx x14 days: Restrict PPI triple tx (PPI + amoxicillin + clarithro OR PPI + metronidazole + clarithro for 14 days) to areas w/ known low clarithro resistance (<15%) or proven high local eradication rates (>85%).
Not Recommended
• Recommends against sequential nonbismuth quadruple tx (PPI + amoxicillin, followed by PPI + metronidazole + clarithro) as 1st-line tx.
• Recommends against use of levofloxacin triple tx (PPI + amoxicillin + levofloxacin) as 1st-line tx.
Fallone CA, et al. Consensus Statement. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology. 2016. Jul;151(1):51-69.e14. PubMed® abstract
3 Maastricht VI/Florence Consensus 2022.
Recommended Tx
• Clarithro triple tx x14 days as 1st-line empirical tx in areas of low clarithro resistance and confirmed ≥90% effectiveness, unless shorter therapies are proven effective locally. Use of high-dose PPI bid increases efficacy and can be crucial for eradication in extensive PPI metabolizers, who are more prevalent in Caucasian vs Asian populations.
• Bismuth quadruple tx x14 days, unless 10-day therapies proven effective locally. Dual tx w/ high-dose PPI or potassium-competitive acid blocker (PCAB; vonoprazan where avail.) + amoxicillin (+/- rifabutin, where avail.) may be another option, if confirmed effective locally.
Malfertheiner P, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022. Aug 8;gutjnl-2022-327745. Doi: 10.1136/gutjnl-2022-327745. Online ahead of print. PDF Only a minority of pts presenting w/ hx of PCN allergy have evidence of immune-mediated hypersensitivity. Negative allergy testing enables the use of PCN so these pts aren’t excluded from the best tx.3 Treat x10-14 days, depending on abx regimen;1-3 test success of H. pylori eradication tx.
- Treat x14 days for all regimens (per ACG and Toronto);1,2 14 days unless shorter/10-day tx proven effective locally (per Maastricht/Florence).3
- Ask about previous abx exposure to help determine 1st-line tx;1 consider regional abx resistance patterns (when avail.)1-3 and eradication rates when choosing 1st-line tx;2 clarithro susceptibility testing, if avail. through molecular techniques or cx, is recommended before prescribing any clarithro-containing tx,3 but these tests not widely avail. in the U.S.
- Test success of eradication tx: Use urea breath test, fecal antigen test, or bx at least 4wk after tx completion and after withholding PPI tx for 1-2wk.1,3
Footnotes 1 ACG 2024.
Recommended Tx
• Bismuth quadruple tx x14 days.
Not Recommended
• PPI-clarithro triple tx x14 days.
Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep;119(9):1730-1753. Full-text article
2 Toronto Consensus 2016.
Recommended Tx
• Bismuth quadruple tx x14 days.
• PPI triple tx x14 days: Restrict PPI triple tx (PPI + amoxicillin + clarithro OR PPI + metronidazole + clarithro for 14 days) to areas w/ known low clarithro resistance (<15%) or proven high local eradication rates (>85%).
Fallone CA, et al. Consensus Statement. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology. 2016. Jul;151(1):51-69.e14. PubMed® abstract
3 Maastricht VI/Florence Consensus 2022.
Recommended Tx
• Bismuth quadruple tx x14 days, unless 10-day therapies proven effective.
• PPI triple tx may be used in area w/ low clarithro or metronidazole resistance if bismuth not avail. Extend duration to 14 days, unless shorter therapies are proven effective locally.
• Possible strategies to increase eradication include adding bismuth to PPI triple tx, increasing antisecretory potency w/ a potassium-competitive acid blocker (PCAB; e.g., vonoprazan), substituting amoxicillin w/ cefuroxime, and using regimens containing sitafloxacin or semisynthetic tetracycline (doxycycline or minocycline).
Malfertheiner P, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022. Aug 8;gutjnl-2022-327745. Doi: 10.1136/gutjnl-2022-327745. Online ahead of print. PDF Hx of macrolide exposure or local clarithromycin resistance high (≥15%) Treat x10-14 days, depending on abx regimen;1-3 test success of H. pylori eradication tx. - Treat x14 days for all regimens (per ACG and Toronto);1,2 14 days unless shorter/10-day tx proven effective locally (per Maastricht/Florence).3
- Ask about previous abx exposure to help determine 1st-line tx;1 consider regional abx resistance patterns (when avail.)1-3 and eradication rates when choosing 1st-line tx;2 clarithro susceptibility testing, if avail. through molecular techniques or cx, is recommended before prescribing any clarithro-containing tx,3 but these tests not widely avail. in the U.S.
- Test success of eradication tx: Use urea breath test, fecal antigen test, or bx at least 4wk after tx completion and after withholding PPI tx for 1-2wk.1,3
Footnotes 1 ACG 2024.
Recommended Tx
• Bismuth quadruple tx x14 days.
Suggested Tx
• Rifabutin triple tx x14 days.
• PCAB dual tx x14 days.
Not Recommended
• Levofloxacin triple tx x10-14 days.
• Fluoroquinolone sequential tx x5-7 days.
Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep;119(9):1730-1753. Full-text article
2 Toronto Consensus 2016.
Recommended Tx
• Bismuth quadruple tx x14 days.
• Concomitant nonbismuth quadruple tx x14 days.
Not Recommended
• Recommends against sequential nonbismuth quadruple tx (PPI + amoxicillin, followed by PPI + metronidazole + clarithro) as 1st-line tx.
• Recommends against use of levofloxacin triple tx (PPI + amoxicillin + levofloxacin) as 1st-line tx.
Fallone CA, et al. Consensus Statement. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology. 2016. Jul;151(1):51-69.e14. PubMed® abstract
3 Maastricht VI/Florence Consensus 2022.
Recommended Tx
Area w/ High Clarithro Resistance
• Bismuth quadruple tx x14 days, unless 10-day therapies proven effective locally.
• Concomitant nonbismuth quadruple tx x14 days, unless 10-day therapies proven effective locally, if bismuth quadruple locally unavail.
Area w/ High Dual Clarithro/Metronidazole Resistance
• Bismuth quadruple tx x14 days, unless 10-day therapies proven effective locally. If bismuth, tetracycline, or Pylera (bismuth subcitrate potassium/ metronidazole/ tetracycline) not avail., may consider high-dose PPI-amoxicillin dual tx or rifabutin triple tx, but the success of these regimens hasn’t been consistently above 90%. Also, bone marrow suppression can occur w/ rifabutin triple tx.
Malfertheiner P, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022. Aug 8;gutjnl-2022-327745. Doi: 10.1136/gutjnl-2022-327745. Online ahead of print. PDF Only a minority of pts presenting w/ hx of PCN allergy have evidence of immune-mediated hypersensitivity. Negative allergy testing enables the use of PCN so these pts aren’t excluded from the best tx.3 Treat x10-14 days, depending on abx regimen;1-3 test success of H. pylori eradication tx. - Treat x14 days for all regimens (per ACG and Toronto);1,2 14 days unless shorter/10-day tx proven effective locally (per Maastricht/Florence).3
- Ask about previous abx exposure to help determine 1st-line tx;1 consider regional abx resistance patterns (when avail.)1-3 and eradication rates when choosing 1st-line tx.2
- Test success of eradication tx: Use urea breath test, fecal antigen test, or bx at least 4wk after tx completion and after withholding PPI tx for 1-2wk.1,3
Footnotes 1 ACG 2024.
Recommended Tx
• Bismuth quadruple tx x14 days.
Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep;119(9):1730-1753. Full-text article
2 Toronto Consensus 2016.
Recommended Tx
• Bismuth quadruple tx x14 days; for efficacy; for duration.
Fallone CA, et al. Consensus Statement. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology. 2016. Jul;151(1):51-69.e14. PubMed® abstract
3 Maastricht VI/Florence Consensus 2022.
Recommended Tx
• Bismuth quadruple tx x14 days, unless 10-day therapies proven effective locally.
• Possible strategies to increase eradication include adding bismuth to PPI triple tx, increasing antisecretory potency w/ a potassium-competitive acid blocker (PCAB; e.g., vonoprazan), substituting amoxicillin w/ cefuroxime, and using regimens containing sitafloxacin or semisynthetic tetracycline (doxycycline or minocycline).
Malfertheiner P, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022. Aug 8;gutjnl-2022-327745. Doi: 10.1136/gutjnl-2022-327745. Online ahead of print. PDF -
Adult | Failed initial tx
Initial tx regimen included clarithromycin After 1st failure, treat for at least 10-14 days. - When selecting salvage regimen: Consider local antimicrobial resistance data and pt’s previous exposure to abx; avoid abx previously used.1-3
- If pt received 1st-line tx containing clarithro: Optimized bismuth quadruple tx is preferred.1
◦ If bismuth or tetracycline unavail.: Rifabutin triple tx is suitable alternative. If pt can’t take rifabutin (e.g., due to true PCN allergy), conduct susceptibility testing to guide further tx w/ salvage regimens.
◦ If testing shows clarithro susceptibility: PPI- or PCAB-clarithro triple tx suggested. Pts infected w/ H. pylori susceptible to clarithro and amoxicillin may consider repeating clarithro triple tx if opportunity for optimization of gastric acid suppression—e.g., if pt fails initial PPI-clarithro triple tx, may consider esomeprazole, rabeprazole, or PCAB in salvage regimen if not used in previous regimen. - Antimicrobial susceptibility testing provides the opportunity to tailor tx, minimizing the emergence of future antibiotic resistance, but evidence in support of the routine use of susceptibility-guided tx after H. pylori eradication failure is limited.3
Footnotes 1 ACG 2024.
Recommended Tx
• Optimized bismuth quadruple tx x14 days.
Other Options
• Rifabutin triple tx x14 days.
• Levofloxacin triple tx x14 days.
No Recommendation
• High-dose dual tx x14 days.
Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep;119(9):1730-1753. Full-text article
2 Toronto Consensus 2016.
Recommended Tx
• Bismuth quadruple tx x14 days.
• Levofloxacin-containing tx x14 days.
• Rifabutin restricted (after failure of ≥3 options) tx x14 days.
Not Recommended
• Recommends against use of clarithro-containing regimens as subsequent tx in pts who previously failed to respond to clarithro-containing H. pylori eradication tx.
• Don’t use sequential nonbismuth quadruple tx (PPI + amoxicillin, followed by PPI + metronidazole + clarithro) as option for subsequent tx.
Fallone CA, et al. Consensus Statement. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology. 2016. Jul;151(1):51-69.e14. PubMed® abstract
3 Maastricht VI/Florence Consensus 2022.
Tx Recommendations – After Failed Initial Tx
• After failure of PPI-clarithro-amoxicillin triple tx: a bismuth-containing quadruple tx (BQT), a fluoroquinolone (FQ)-containing quadruple (or triple) tx, or a PPI-amoxicillin high-dose dual tx is recommended as a 2nd-line tx.
• After failure of a nonbismuth quadruple tx, either BQT or an FQ-containing quadruple (or triple) tx is recommended. May also consider PPI-amoxicillin high-dose dual tx.
Tx Recommendations – After Failed 2nd-Line Tx
• After failure of 1st-line tx (clarithro-based) and 2nd-line tx (w/ bismuth-containing quadruple regimen), use FQ-containing regimen. In regions w/ known high FQ resistance, consider a combo of bismuth w/ different abx, rifabutin-containing rescue tx, or a high-dose PPI-amoxicillin dual tx.
• After failure of 1st-line tx (clarithro-based) and 2nd-line tx (FQ-containing tx), use BQT. If bismuth not avail., consider high-dose PPI-amoxicillin dual tx or a rifabutin-containing regimen.
Malfertheiner P, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022. Aug 8;gutjnl-2022-327745. Doi: 10.1136/gutjnl-2022-327745. Online ahead of print. PDF Only a minority of pts presenting w/ hx of PCN allergy have evidence of immune-mediated hypersensitivity. Negative allergy testing enables the use of PCN so these pts aren’t excluded from the best tx.3 After 1st failure, treat for at least 10-14 days. - When selecting salvage regimen: Consider local antimicrobial resistance data and pt’s previous exposure to abx; avoid abx previously used.1-3
- If pt received 1st-line tx containing clarithro: Optimized bismuth quadruple tx is preferred.1
- If bismuth or tetracycline unavail. and PCN allergy: Consider allergy testing.1
◦ If true PCN allergy, conduct susceptibility testing to guide further tx w/ salvage regimens.
◦ If testing shows clarithro susceptibility: PPI- or PCAB-clarithro triple tx suggested. Pts infected w/ H. pylori susceptible to clarithro and amoxicillin may consider repeating clarithro triple tx if opportunity for optimization of gastric acid suppression—e.g., if pt fails initial PPI-clarithro triple tx, may consider esomeprazole, rabeprazole, or PCAB in salvage regimen if not used in previous regimen. - Antimicrobial susceptibility testing provides the opportunity to tailor tx, minimizing the emergence of future antibiotic resistance, but evidence in support of the routine use of susceptibility-guided tx after H. pylori eradication failure is limited.3
Footnotes 1 ACG 2024.
Recommended Tx
• Optimized bismuth quadruple tx x14 days.
Other Options
• Levofloxacin triple tx x14 days.
Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep;119(9):1730-1753. Full-text article
2 Toronto Consensus 2016.
Recommended Tx
• Bismuth quadruple tx x14 days.
Not Recommended
• Recommends against use of clarithro-containing regimens as subsequent tx in pts who previously failed to respond to clarithro-containing H. pylori eradication tx.
Fallone CA, et al. Consensus Statement. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology. 2016. Jul;151(1):51-69.e14. PubMed® abstract
3 Maastricht VI/Florence Consensus 2022.
Tx Recommendations – After Failed Initial Tx
• After failure of PPI-clarithro-amoxicillin triple tx: a bismuth-containing quadruple tx (BQT) or a fluoroquinolone (FQ)-containing quadruple (or triple) tx is recommended as a 2nd-line tx.
• After failure of a nonbismuth quadruple tx, either BQT or an FQ-containing quadruple (or triple) tx is recommended.
• Rescue regimen: FQ-containing regimens in various combos (e.g., w/ clarithro) are also effective, but resistance is acquired easily and is relatively high in countries w/ high FQ consumption.
Tx Recommendations – After Failed 2nd-Line Tx
• After failure of 1st-line tx (clarithro-based) and 2nd-line tx (w/ bismuth-containing quadruple regimen), use FQ-containing regimen. In regions w/ known high FQ resistance, consider a combo of bismuth w/ different abx or a rifabutin-containing rescue tx.
• After failure of 1st-line tx (clarithro-based) and 2nd-line tx (FQ-containing tx), use bismuth-based quadruple tx. If bismuth not avail., consider a rifabutin-containing regimen.
Possible strategies to increase eradication include adding bismuth to PPI triple tx, increasing antisecretory potency w/ a potassium-competitive acid blocker (PCAB; e.g., vonoprazan), substituting amoxicillin w/ cefuroxime, and using regimens containing sitafloxacin or semisynthetic tetracycline (doxycycline or minocycline).
Malfertheiner P, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022. Aug 8;gutjnl-2022-327745. Doi: 10.1136/gutjnl-2022-327745. Online ahead of print. PDF After 1st failure, treat for at least 14 days. - When selecting salvage regimen: Consider local antimicrobial resistance data and pt’s previous exposure to abx; avoid abx previously used.1-3
- If pt received 1st-line tx containing clarithro: Optimized bismuth quadruple tx is preferred.1
◦ If bismuth or tetracycline unavail.: Rifabutin triple tx is suitable alternative. If pt can’t take rifabutin (e.g., due to true PCN allergy), conduct susceptibility testing to guide further tx w/ salvage regimens.
◦ If testing shows clarithro susceptibility: PPI- or PCAB-clarithro triple tx suggested. Pts infected w/ H. pylori susceptible to clarithro and amoxicillin may consider repeating clarithro triple tx if opportunity for optimization of gastric acid suppression—e.g., if pt fails initial PPI-clarithro triple tx, may consider esomeprazole, rabeprazole, or PCAB in salvage regimen if not used in previous regimen. - Antimicrobial susceptibility testing provides the opportunity to tailor tx, minimizing the emergence of future antibiotic resistance, but evidence in support of the routine use of susceptibility-guided tx after H. pylori eradication failure is limited.3
Footnotes 1 ACG 2024.
Recommended Tx
• Optimized bismuth quadruple tx x14 days.
Other Options
• Rifabutin triple tx x14 days.
No Recommendation
• High-dose dual tx x14 days.
Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep;119(9):1730-1753. Full-text article
2 Toronto Consensus 2016.
Recommended Tx
• Bismuth quadruple tx x14 days.
• Rifabutin restricted (after failure of ≥3 options) tx x14 days.
Not Recommended
• Recommends against use of clarithro-containing regimens as subsequent tx in pts who previously failed to respond to clarithro-containing H. pylori eradication tx.
• Don’t use sequential nonbismuth quadruple tx (PPI + amoxicillin, followed by PPI + metronidazole + clarithro) as option for subsequent tx.
Fallone CA, et al. Consensus Statement. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology. 2016. Jul;151(1):51-69.e14. PubMed® abstract
3 Maastricht VI/Florence Consensus 2022.
Recommended Tx – After Failed Initial Tx
• Bismuth quadruple tx.
• High-dose PPI + amoxicillin dual tx.
• Potassium-competitive acid blocker (PCAB; vonoprazan where avail.) + amoxicillin tx.
Tx Recommendations – After Failed 2nd-Line Tx
• After failure of 1st-line tx (clarithro-based) and 2nd-line tx (w/ bismuth-containing quadruple regimen), use a fluoroquinolone (FQ)-containing regimen. In regions w/ known high FQ resistance, consider a combo of bismuth w/ different abx, rifabutin-containing rescue tx, or a high-dose PPI-amoxicillin dual tx.
• After failure of 1st-line tx (clarithro-based) and 2nd-line tx (FQ-containing tx), use bismuth-based quadruple tx. If bismuth not avail., consider high-dose PPI-amoxicillin dual tx or a rifabutin-containing regimen.
Malfertheiner P, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022. Aug 8;gutjnl-2022-327745. Doi: 10.1136/gutjnl-2022-327745. Online ahead of print. PDF Only a minority of pts presenting w/ hx of PCN allergy have evidence of immune-mediated hypersensitivity. Negative allergy testing enables the use of PCN so these pts aren’t excluded from the best tx.3 After 1st failure, treat for at least 14 days. - When selecting salvage regimen: Consider local antimicrobial resistance data and pt’s previous exposure to abx; avoid abx previously used.1-3
- If pt received 1st-line tx containing clarithro: Optimized bismuth quadruple tx is preferred.1
- If bismuth or tetracycline unavail. and PCN allergy: Consider allergy testing.1
◦ If true PCN allergy, conduct susceptibility testing to guide further tx w/ salvage regimens.
◦ If testing shows clarithro susceptibility: PPI- or PCAB-clarithro triple tx suggested. Pts infected w/ H. pylori susceptible to clarithro and amoxicillin may consider repeating clarithro triple tx if opportunity for optimization of gastric acid suppression—e.g., if pt fails initial PPI-clarithro triple tx, may consider esomeprazole, rabeprazole, or PCAB in salvage regimen if not used in previous regimen. - Antimicrobial susceptibility testing provides the opportunity to tailor tx, minimizing the emergence of future antibiotic resistance, but evidence in support of the routine use of susceptibility-guided tx after H. pylori eradication failure is limited.3
Footnotes 1 ACG 2024.
Recommended Tx
• Optimized bismuth quadruple tx x14 days.
Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep;119(9):1730-1753. Full-text article
2 Toronto Consensus 2016.
Recommended Tx
• Bismuth quadruple tx x14 days.
Not Recommended
• Recommends against use of clarithro-containing regimens as subsequent tx in pts who previously failed to respond to clarithro-containing H. pylori eradication tx.
Fallone CA, et al. Consensus Statement. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology. 2016. Jul;151(1):51-69.e14. PubMed® abstract
3 Maastricht VI/Florence Consensus 2022.
Recommended Tx – After Failed Initial Tx
• Bismuth quadruple tx.
Tx Recommendations – After Failed 2nd-Line Tx
• After failure of 1st-line tx (clarithro-based) and 2nd-line tx (w/ bismuth-containing quadruple regimen), use a fluoroquinolone (FQ)-containing regimen. In regions w/ known high FQ resistance, consider a combo of bismuth w/ different abx or a rifabutin-containing rescue tx.
• After failure of 1st-line tx (clarithro-based) and 2nd-line tx (FQ-containing tx), use bismuth-based quadruple tx. If bismuth not avail., consider a rifabutin-containing regimen.
Possible strategies to increase eradication include adding bismuth to PPI triple tx, increasing antisecretory potency w/ a potassium-competitive acid blocker (PCAB; e.g., vonoprazan), substituting amoxicillin w/ cefuroxime, and using regimens containing sitafloxacin or semisynthetic tetracycline (doxycycline or minocycline).
Malfertheiner P, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022. Aug 8;gutjnl-2022-327745. Doi: 10.1136/gutjnl-2022-327745. Online ahead of print. PDF Initial tx regimen didn’t include clarithromycin After 1st failure, treat for at least 10-14 days. - When selecting salvage regimen: Consider local antimicrobial resistance data and pt’s previous exposure to abx; avoid abx previously used.1-3
- If pt didn’t receive bismuth quadruple tx (BQT) or optimized BQT as 1st-line tx: Optimized BQT preferred.1
- If pt received 1st-line optimized BQT, or bismuth or tetracycline unavail.: Rifabutin triple tx is suitable alternative. If pt can’t take rifabutin (e.g., due to true PCN allergy), conduct susceptibility testing to guide further tx w/ salvage regimens.1
- Don’t use sequential nonbismuth quadruple tx (PPI + amoxicillin, followed by PPI + metronidazole + clarithro) as subsequent tx option.2
- Antimicrobial susceptibility testing provides the opportunity to tailor tx, minimizing the emergence of future antibiotic resistance, but evidence in support of the routine use of susceptibility-guided tx after H. pylori eradication failure is limited.3
Footnotes 1 ACG 2024.
Recommended Tx
• Optimized bismuth quadruple tx x14 days.
Other Options
• Rifabutin triple tx x14 days.
• Levofloxacin triple tx x14 days.
No Recommendation
• PCAB triple tx x14 days.
• High-dose dual tx x14 days.
Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep;119(9):1730-1753. Full-text article
2 Toronto Consensus 2016.
Recommended Tx
• Levofloxacin-containing tx x14 days.
• Optimized bismuth quadruple tx x14 days.
• Rifabutin restricted (after failure of ≥3 options) tx x14 days.
Not Recommended
• Don’t use sequential nonbismuth quadruple tx (PPI + amoxicillin, followed by PPI + metronidazole + clarithro) as option for subsequent tx.
Fallone CA, et al. Consensus Statement. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology. 2016. Jul;151(1):51-69.e14. PubMed® abstract
3 Maastricht VI/Florence Consensus 2022.
Recommended Tx – After Failed Initial Tx
• Fluoroquinolone triple tx.
• Fluoroquinolone quadruple tx.
• High-dose PPI-amoxicillin dual tx.
Tx Recommendations – After Failed 2nd-Line Tx
• After failure of 1st-line tx w/ bismuth quadruple and 2nd-line tx (fluoroquinolone-containing tx), use a clarithro-based triple or quadruple tx only in area of low (<15%) clarithro resistance. Otherwise, use a high-dose PPI-amoxicillin dual tx, a rifabutin-containing regimen, or a combo of bismuth w/ different abx.
Malfertheiner P, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022. Aug 8;gutjnl-2022-327745. Doi: 10.1136/gutjnl-2022-327745. Online ahead of print. PDF Only a minority of pts presenting w/ hx of PCN allergy have evidence of immune-mediated hypersensitivity. Negative allergy testing enables the use of PCN so these pts aren’t excluded from the best tx.3 After 1st failure, treat for at least 14 days. - When selecting salvage regimen: Consider local antimicrobial resistance data and pt’s previous exposure to abx; avoid abx previously used.1-3
- If PCN allergy: Consider allergy testing.1
- If pt didn’t receive bismuth quadruple tx (BQT) or optimized BQT as 1st-line tx: Optimized BQT preferred.1
- If pt received 1st-line optimized BQT, or bismuth or tetracycline unavail., and true PCN allergy: Conduct susceptibility testing to guide further tx w/ salvage regimens.1
- Don’t use sequential nonbismuth quadruple tx (PPI + amoxicillin, followed by PPI + metronidazole + clarithro) as subsequent tx option.2
- Antimicrobial susceptibility testing provides the opportunity to tailor tx, minimizing the emergence of future antibiotic resistance, but evidence in support of the routine use of susceptibility-guided tx after H. pylori eradication failure is limited.3
Footnotes 1 ACG 2024.
Recommended Tx
• Optimized bismuth quadruple tx x14 days.
Other Options
• Levofloxacin triple tx x14 days.
Most pts w/ PCN allergy hx don’t have true PCN hypersensitivity. After failure of 1st-line tx, consider these pts for referral for allergy testing; vast majority can ultimately take amox-containing salvage regimens safely.
Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep;119(9):1730-1753. Full-text article
2 Toronto Consensus 2016.
Recommended Tx
• Optimized bismuth quadruple tx x14 days.
Fallone CA, et al. Consensus Statement. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology. 2016. Jul;151(1):51-69.e14. PubMed® abstract
3 Maastricht VI/Florence Consensus 2022.
Recommended Tx – After Failed Initial Tx
• Rescue regimen: A fluoroquinolone (FQ)-containing regimen may represent an empirical 2nd-line rescue option in the presence of PCN allergy.
Tx Recommendations – After Failed 2nd-Line Tx
• After failure of 1st-line tx w/ bismuth quadruple and 2nd-line tx (FQ-containing tx), use a rifabutin-containing regimen or a combo of bismuth w/ different abx.
Possible strategies to increase eradication include adding bismuth to PPI triple tx, increasing antisecretory potency w/ a potassium-competitive acid blocker (PCAB; e.g., vonoprazan), substituting amoxicillin w/ cefuroxime, and using regimens containing sitafloxacin or semisynthetic tetracycline (doxycycline or minocycline).
Malfertheiner P, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022. Aug 8;gutjnl-2022-327745. Doi: 10.1136/gutjnl-2022-327745. Online ahead of print. PDF After 1st failure, treat for at least 10-14 days. - When selecting salvage regimen: Consider local antimicrobial resistance data and pt’s previous exposure to abx; avoid abx previously used.1-3
- If pt didn’t receive bismuth quadruple tx (BQT) or optimized BQT as 1st-line tx: Optimized BQT preferred.1
- If pt received 1st-line optimized BQT, or bismuth or tetracycline unavail.: Rifabutin triple tx is suitable alternative. If pt can’t take rifabutin (e.g., due to true PCN allergy), conduct susceptibility testing to guide further tx w/ salvage regimens.1
- If pt received 1st-line levofloxacin-containing tx: Don’t use levofloxacin-containing salvage regimens.2
- Don’t use sequential nonbismuth quadruple tx (PPI + amoxicillin, followed by PPI + metronidazole + clarithro).2
- Antimicrobial susceptibility testing provides the opportunity to tailor tx, minimizing the emergence of future antibiotic resistance, but evidence in support of the routine use of susceptibility-guided tx after H. pylori eradication failure is limited.3
Footnotes 1 ACG 2024.
Recommended Tx
• Optimized bismuth quadruple tx x14 days.
Other Options
• Rifabutin triple tx x14 days.
No Recommendation
• PCAB triple tx x14 days.
• High-dose dual tx x14 days.
Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep;119(9):1730-1753. Full-text article
2 Toronto Consensus 2016.
Recommended Tx
• Optimized bismuth quadruple tx x14 days.
• Rifabutin restricted (after failure of ≥3 options) tx x14 days.
Not Recommended
• Don’t use sequential nonbismuth quadruple tx (PPI + amoxicillin, followed by PPI + metronidazole + clarithro) as option for subsequent tx.
Fallone CA, et al. Consensus Statement. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology. 2016. Jul;151(1):51-69.e14. PubMed® abstract
3 Maastricht VI/Florence Consensus 2022.
Recommended Tx – After Failed Initial Tx
• High-dose PPI-amoxicillin dual tx.
• Bismuth w/ different abx.
• Rifabutin-containing rescue.
Tx Recommendations – After Failed 2nd-Line Tx
• After failure of 1st-line tx w/ bismuth quadruple and 2nd-line tx (high-dose PPI-amoxicillin dual tx), use a clarithro-based triple or quadruple tx only in area of low (<15%) clarithro resistance. Otherwise, use a rifabutin-containing regimen or a combo of bismuth w/ different abx.
Malfertheiner P, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022. Aug 8;gutjnl-2022-327745. Doi: 10.1136/gutjnl-2022-327745. Online ahead of print. PDF Only a minority of pts presenting w/ hx of PCN allergy have evidence of immune-mediated hypersensitivity. Negative allergy testing enables the use of PCN so these pts aren’t excluded from the best tx.3 After 1st failure, treat for at least 14 days. - When selecting salvage regimen: Consider local antimicrobial resistance data and pt’s previous exposure to abx; avoid abx previously used.1-3
- If pt didn’t receive bismuth quadruple tx (BQT) or optimized BQT as 1st-line tx: Optimized BQT preferred.1
- If pt received 1st-line optimized BQT, or bismuth or tetracycline unavail., and PCN allergy: Consider allergy testing.1
- If pt received 1st-line levofloxacin-containing tx: Don’t use levofloxacin-containing salvage regimens.2
- Don’t use sequential nonbismuth quadruple tx (PPI + amoxicillin, followed by PPI + metronidazole + clarithro).2
- Antimicrobial susceptibility testing provides the opportunity to tailor tx, minimizing the emergence of future antibiotic resistance, but evidence in support of the routine use of susceptibility-guided tx after H. pylori eradication failure is limited.3
Footnotes 1 ACG 2024.
Recommended Tx
• Optimized bismuth quadruple tx x14 days.
Most pts w/ PCN allergy hx don’t have true PCN hypersensitivity. After failure of 1st-line tx, consider these pts for referral for allergy testing; vast majority can ultimately take amox-containing salvage regimens safely.
Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep;119(9):1730-1753. Full-text article
2 Toronto Consensus 2016.
Recommended Tx
• Optimized bismuth quadruple tx x14 days.
Fallone CA, et al. Consensus Statement. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology. 2016. Jul;151(1):51-69.e14. PubMed® abstract
3 Maastricht VI/Florence Consensus 2022.
Recommended Tx – After Failed Initial Tx
• Bismuth w/ different abx or rifabutin-containing rescue.
Tx Recommendations – After Failed 2nd-Line Tx
• After failure of 1st-line tx w/ bismuth quadruple and 2nd-line tx (bismuth w/ different abx), use a rifabutin-containing rescue.
• After failure of 1st-line tx w/ bismuth quadruple and 2nd-line tx (rifabutin-containing rescue), use bismuth w/ different abx.
Possible strategies to increase eradication include adding bismuth to PPI triple tx, increasing antisecretory potency w/ a potassium-competitive acid blocker (PCAB; e.g., vonoprazan), substituting amoxicillin w/ cefuroxime, and using regimens containing sitafloxacin or semisynthetic tetracycline (doxycycline or minocycline).
Malfertheiner P, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022. Aug 8;gutjnl-2022-327745. Doi: 10.1136/gutjnl-2022-327745. Online ahead of print. PDF -
Child/Adolescent | Awaiting initial tx
H. pylori susceptible to clarithromycin and metronidazole Treat for 10-14 days depending on abx regimen; test success of H. pylori eradication tx1 - Tailor tx according to antimicrobial susceptibility; consider national/regional abx resistance patterns when antimicrobial susceptibility testing is not avail.
- Explain to family the importance of adherence to selected regimen
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx; younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15min prior to meals
- Sequential tx w/ amoxicillin + clarithromycin + metronidazole is equally effective as other 1st-line therapies, but exposes pts to 3 abx
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk
Drug links | Antimicrobials Drug links | Acid suppressive Tx Footnotes 1 Jones NL, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017. Jun;64(6):991-1003. Free full-text article PDF
Treat for 10-14 days depending on abx regimen; test success of H. pylori eradication tx1 - Tailor tx according to antimicrobial susceptibility; consider national/regional abx resistance patterns when antimicrobial susceptibility testing is not avail.
- Explain to family the importance of adherence to selected regimen
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx; younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15min prior to meals
- Sequential tx w/ amoxicillin + clarithromycin + metronidazole is equally effective as other 1st-line therapies, but exposes pts to 3 abx
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk
Drug links | Antimicrobials Drug links | Acid suppressive Tx Footnotes 1 Jones NL, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017. Jun;64(6):991-1003. Free full-text article PDF
Treat for 10-14 days depending on abx regimen; test success of H. pylori eradication tx1 - Tailor tx according to antimicrobial susceptibility; consider national/regional abx resistance patterns when antimicrobial susceptibility testing is not avail.
- Explain to family the importance of adherence to selected regimen
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx; younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15min prior to meals
- Sequential tx w/ amoxicillin + clarithromycin + metronidazole is equally effective as other 1st-line therapies, but exposes pts to 3 abx
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk
Drug links | Antimicrobials Drug links | Acid suppressive Tx Footnotes 1 Jones NL, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017. Jun;64(6):991-1003. Free full-text article PDF
H. pylori resistant to clarithromycin, but metronidazole susceptible Treat for 14 days; test success of H. pylori eradication tx1 - Tailor tx according to antimicrobial susceptibility;1 consider national/regional abx resistance patterns when antimicrobial susceptibility testing is not avail.
- Explain to family the importance of adherence to selected regimen1
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx;1 younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15min prior to meals
- PCN allergy in pts 8 yo & older: May consider replacing amoxicillin w/ tetracycline in bismuth-based regimen, although tetracycline dosing in pediatric pts is not defined;1 alternative regimens lacking for PCN-allergic pts <8 yo1-3
- Do not replace tetracycline w/ doxycycline;4 doxycycline is not as effective as tetracycline for H. pylori infections
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk1
Drug links | Antimicrobials Drug links | Acid suppressive Tx Footnotes 1 Jones NL, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017. Jun;64(6):991-1003. Free full-text article PDF
2 Jun JS, et al. Changes in the Treatment Strategies for Helicobacter pylori Infection in Children and Adolescents in Korea. Pediatr Gastroenterol Hepatol Nutr. 2019. Sep;22(5):417-430. PubMed® abstract | Free full-text article PDF @ PubMed® Central
3 Aguilera Matos I, et al. Helicobacter pylori Infection in Children. BMJ Paediatr Open. 2020. Aug 3;4(1):e000679. PubMed® abstract | Free full-text article PDF @ PubMed®
4 Liou JM, et al. Efficacies of Genotypic Resistance-Guided vs Empirical Therapy for Refractory Helicobacter pylori Infection. Gastroenterology. 2018 Oct;155(4):1109-1119. PubMed® abstract H. pylori susceptible to clarithromycin, but metronidazole resistant Treat for 14 days; test success of H. pylori eradication tx1 - Tailor tx according to antimicrobial susceptibility;1 consider national/regional abx resistance patterns when antimicrobial susceptibility testing is not avail.
- Explain to family the importance of adherence to selected regimen1
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx;1 younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15min prior to meals
- PCN allergy: Alternative regimens are lacking for pts w/ H. pylori strains resistant to metronidazole1-3
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk1
Drug links | Antimicrobials Drug links | Acid suppressive Tx H. pylori resistant to clarithromycin and metronidazole or susceptibility unknown Pt weight 15-24 kg: 1st-line tx regimens Pt weight 25-34 kg: 1st-line tx regimens Pt weight >35 kg: 1st-line tx regimens Treat for 14 days; test success of H. pylori eradication tx1 - Tailor tx according to antimicrobial susceptibility;1 consider national/regional abx resistance patterns when antimicrobial susceptibility testing is not avail.
- Explain to family the importance of adherence to selected regimen1
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx;1 younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15min prior to meals
- PCN allergy: Tx options are not defined1-3
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk1
Drug links | Antimicrobials Drug links | Acid suppressive Tx -
Child/Adolescent | Failed initial tx
H. pylori initially susceptible to clarithromycin and metronidazole After a 1st-failure, tx for at least 14 days1 - When selecting rescue tx: Consider abx susceptibility, pt’s age, and avail. abx options;1 avoid abx used in initial therapy
- Explain to family the importance of adherence to selected regimen1
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx;1 younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15min prior to meals
- If initial tx w/ sequential tx, consider repeat endoscopy: Use results to tailor tx x14 days1
- Adolescents w/ initial tx w/ sequential tx: May consider tetracycline or levofloxacin as part of the regimen,1 although dosing in adolescents for H. pylori infection is not defined
- Do not replace tetracycline w/ doxycycline;2 doxycycline is not as effective as tetracycline for H. pylori infections
- PCN allergy: Tx options for pts initially tx w/ metronidazole & clarithromycin are not defined1,3-4
- A study in adults suggests incr acid suppression & metronidazole dose may improve eradiation;5 higher doses of PPI & metronidazole may be considered in children,1 although dosing is not defined
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk1
Drug links | Antimicrobials Drug links | Acid suppressive Tx Footnotes 1 Jones NL, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017. Jun;64(6):991-1003. Free full-text article PDF
2 Liou JM, et al. Efficacies of Genotypic Resistance-Guided vs Empirical Therapy for Refractory Helicobacter pylori Infection. Gastroenterology. 2018 Oct;155(4):1109-1119. PubMed® abstract
3 Jun JS, et al. Changes in the Treatment Strategies for Helicobacter pylori Infection in Children and Adolescents in Korea. Pediatr Gastroenterol Hepatol Nutr. 2019. Sep;22(5):417-430. PubMed® abstract | Free full-text article PDF @ PubMed® Central
4 Aguilera Matos I, et al. Helicobacter pylori Infection in Children. BMJ Paediatr Open. 2020. Aug 3;4(1):e000679. PubMed® abstract | Free full-text article PDF @ PubMed® Central
5 Molina-Infante J, et al. Optimised Empiric Triple and Concomitant Therapy for Helicobacter pylori Eradication in Clinical Practice: The OPTRICON Study. Aliment Pharmacol Ther. 2015. Mar;41(6):581–589. PubMed® abstract
After a 1st-failure, tx for at least 14 days1 - When selecting rescue tx: Consider abx susceptibility, pt’s age, and avail. abx options;1 avoid abx used in initial therapy
- Explain to family the importance of adherence to selected regimen1
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx;1 younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15min prior to meals
- If initial tx w/ sequential tx, consider repeat endoscopy: Use results to tailor tx x14 days1
- Adolescents w/ initial tx w/ sequential tx: May consider tetracycline or levofloxacin as part of the regimen,1 although dosing in adolescents for H. pylori infection is not defined
- Do not replace tetracycline w/ doxycycline;2 doxycycline is not as effective as tetracycline for H. pylori infections
- PCN allergy: Tx options for pts initially tx w/ metronidazole & clarithromycin are not defined1,3-4
- A study in adults suggests incr acid suppression & metronidazole dose may improve eradiation;5 higher doses of PPI & metronidazole may be considered in children,1 although dosing is not defined
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk1
Drug links | Antimicrobials Drug links | Acid suppressive Tx Footnotes 1 Jones NL, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017. Jun;64(6):991-1003. Free full-text article PDF
2 Liou JM, et al. Efficacies of Genotypic Resistance-Guided vs Empirical Therapy for Refractory Helicobacter pylori Infection. Gastroenterology. 2018 Oct;155(4):1109-1119. PubMed® abstract
3 Jun JS, et al. Changes in the Treatment Strategies for Helicobacter pylori Infection in Children and Adolescents in Korea. Pediatr Gastroenterol Hepatol Nutr. 2019. Sep;22(5):417-430. PubMed® abstract | Free full-text article PDF @ PubMed® Central
4 Aguilera Matos I, et al. Helicobacter pylori Infection in Children. BMJ Paediatr Open. 2020. Aug 3;4(1):e000679. PubMed® abstract | Free full-text article PDF @ PubMed® Central
5 Molina-Infante J, et al. Optimised Empiric Triple and Concomitant Therapy for Helicobacter pylori Eradication in Clinical Practice: The OPTRICON Study. Aliment Pharmacol Ther. 2015. Mar;41(6):581–589. PubMed® abstract
After a 1st-failure, tx for at least 14 days1 - When selecting rescue tx: Consider abx susceptibility, pt’s age, and avail. abx options;1 avoid abx used in initial therapy
- Explain to family the importance of adherence to selected regimen1
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx;1 younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15min prior to meals
- If initial tx w/ sequential tx, consider repeat endoscopy: Use results to tailor tx x14 days1
- Adolescents w/ initial tx w/ sequential tx: May consider tetracycline or levofloxacin as part of the regimen,1 although dosing in adolescents for H. pylori infection is not defined
- Do not replace tetracycline w/ doxycycline;2 doxycycline is not as effective as tetracycline for H. pylori infections
- PCN allergy: Tx options for pts initially tx w/ metronidazole & clarithromycin are not defined1,3-4
- A study in adults suggests incr acid suppression & metronidazole dose may improve eradiation;5 higher doses of PPI & metronidazole may be considered in children,1 although dosing is not defined
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk1
Drug links | Antimicrobials Drug links | Acid suppressive Tx Footnotes 1 Jones NL, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017. Jun;64(6):991-1003. Free full-text article PDF
2 Liou JM, et al. Efficacies of Genotypic Resistance-Guided vs Empirical Therapy for Refractory Helicobacter pylori Infection. Gastroenterology. 2018 Oct;155(4):1109-1119. PubMed® abstract
3 Jun JS, et al. Changes in the Treatment Strategies for Helicobacter pylori Infection in Children and Adolescents in Korea. Pediatr Gastroenterol Hepatol Nutr. 2019. Sep;22(5):417-430. PubMed® abstract | Free full-text article PDF @ PubMed® Central
4 Aguilera Matos I, et al. Helicobacter pylori Infection in Children. BMJ Paediatr Open. 2020. Aug 3;4(1):e000679. PubMed® abstract | Free full-text article PDF @ PubMed® Central
5 Molina-Infante J, et al. Optimised Empiric Triple and Concomitant Therapy for Helicobacter pylori Eradication in Clinical Practice: The OPTRICON Study. Aliment Pharmacol Ther. 2015. Mar;41(6):581–589. PubMed® abstract
H. pylori initially resistant to clarithromycin, but metronidazole susceptible Pt weight 15-24 kg: Rescue tx regimens Pt weight 25-34 kg: Rescue tx regimens Pt weight >35 kg: Rescue tx regimens After a 1st-failure, tx for at least 14 days1 - When selecting rescue tx: Consider abx susceptibility, pt’s age, & avail. abx options;1 avoid abx used in initial tx
- Explain to family the importance of adherence to selected regimen1
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx;1 younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15min prior to meals
- Adolescents: May consider tetracycline or levofloxacin as part of the regimen,1 although dosing in adolescents for H. pylori infection is not defined
- Do not replace tetracycline w/ doxycycline;2 doxycycline is not as effective as tetracycline for H. pylori infections
- PCN allergy: Tx options for pts initially tx w/ metronidazole & clarithromycin are not defined1,3-4
- A study in adults suggests incr acid suppression & metronidazole dose may improve eradiation;5 higher doses of PPI & metronidazole may be considered in children,1 although dosing is not defined
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk1
Drug links | Antimicrobials Drug links | Acid suppressive Tx Footnotes 1 Jones NL, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017. Jun;64(6):991-1003. Free full-text article PDF
2 Liou JM, et al. Efficacies of Genotypic Resistance-Guided vs Empirical Therapy for Refractory Helicobacter pylori Infection. Gastroenterology. 2018 Oct;155(4):1109-1119. PubMed® abstract
3 Jun JS, et al. Changes in the Treatment Strategies for Helicobacter pylori Infection in Children and Adolescents in Korea. Pediatr Gastroenterol Hepatol Nutr. 2019. Sep;22(5):417-430. PubMed® abstract | Free full-text article PDF @ PubMed® Central
4 Aguilera Matos I, et al. Helicobacter pylori Infection in Children. BMJ Paediatr Open. 2020. Aug 3;4(1):e000679. PubMed® abstract | Free full-text article PDF @ PubMed®
5 Molina-Infante J, et al. Optimised Empiric Triple and Concomitant Therapy for Helicobacter pylori Eradication in Clinical Practice: The OPTRICON Study. Aliment Pharmacol Ther. 2015. Mar;41(6):581–589. PubMed® abstract
H. pylori initially susceptible to clarithromycin, but metronidazole resistant After a 1st-failure, tx for at least 14 days1 - When selecting rescue tx: Consider abx susceptibility, pt’s age, & avail. abx options;1 avoid abx used in initial tx
- Consider repeat endoscopy: Use results to tailor tx x14 days1
- Explain to family the importance of adherence to selected regimen1
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx;1 younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15min prior to meals
- Adolescents: May consider tetracycline or levofloxacin as part of the regimen,1 though dosing in adolescents for H. pylori infection is not defined
- Do not replace tetracycline w/ doxycycline;2 doxycycline is not as effective as tetracycline for H. pylori infections
- PCN allergy: Tx options for pts initially tx w/ metronidazole and clarithromycin are not defined1,3-4
- A study in adults suggests incr acid suppression & metronidazole dose may improve eradiation;5 higher doses of PPI & metronidazole may be considered in children,1 although dosing is not defined
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk1
Drug links | Antimicrobials Drug links | Acid suppressive Tx Footnotes 1 Jones NL, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017. Jun;64(6):991-1003. Free full-text article PDF
2 Liou JM, et al. Efficacies of Genotypic Resistance-Guided vs Empirical Therapy for Refractory Helicobacter pylori Infection. Gastroenterology. 2018 Oct;155(4):1109-1119. PubMed® abstract
3 Jun JS, et al. Changes in the Treatment Strategies for Helicobacter pylori Infection in Children and Adolescents in Korea. Pediatr Gastroenterol Hepatol Nutr. 2019. Sep;22(5):417-430. PubMed® abstract | Free full-text article PDF @ PubMed® Central
4 Aguilera Matos I, et al. Helicobacter pylori Infection in Children. BMJ Paediatr Open. 2020. Aug 3;4(1):e000679. PubMed® abstract | Free full-text article PDF @ PubMed®
5 Molina-Infante J, et al. Optimised Empiric Triple and Concomitant Therapy for Helicobacter pylori Eradication in Clinical Practice: The OPTRICON Study. Aliment Pharmacol Ther. 2015. Mar;41(6):581–589. PubMed® abstract After a 1st-failure, tx for at least 14 days1 - When selecting rescue tx: Consider abx susceptibility, pt’s age, & avail. abx options;1 avoid abx used in initial tx
- Consider repeat endoscopy: Use results to tailor tx x14 days1
- Explain to family the importance of adherence to selected regimen1
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx;1 younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15min prior to meals
- Adolescents: May consider tetracycline or levofloxacin as part of the regimen,1 though dosing in adolescents for H. pylori infection is not defined
- Do not replace tetracycline w/ doxycycline;2 doxycycline is not as effective as tetracycline for H. pylori infections
- PCN allergy: Tx options for pts initially tx w/ metronidazole and clarithromycin are not defined1,3-4
- A study in adults suggests incr acid suppression & metronidazole dose may improve eradiation;5 higher doses of PPI & metronidazole may be considered in children,1 although dosing is not defined
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk1
Drug links | Antimicrobials Drug links | Acid suppressive Tx Footnotes 1 Jones NL, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017. Jun;64(6):991-1003. Free full-text article PDF
2 Liou JM, et al. Efficacies of Genotypic Resistance-Guided vs Empirical Therapy for Refractory Helicobacter pylori Infection. Gastroenterology. 2018 Oct;155(4):1109-1119. PubMed® abstract
3 Jun JS, et al. Changes in the Treatment Strategies for Helicobacter pylori Infection in Children and Adolescents in Korea. Pediatr Gastroenterol Hepatol Nutr. 2019. Sep;22(5):417-430. PubMed® abstract | Free full-text article PDF @ PubMed® Central
4 Aguilera Matos I, et al. Helicobacter pylori Infection in Children. BMJ Paediatr Open. 2020. Aug 3;4(1):e000679. PubMed® abstract | Free full-text article PDF @ PubMed®
5 Molina-Infante J, et al. Optimised Empiric Triple and Concomitant Therapy for Helicobacter pylori Eradication in Clinical Practice: The OPTRICON Study. Aliment Pharmacol Ther. 2015. Mar;41(6):581–589. PubMed® abstract After a 1st-failure, tx for at least 14 days1 - When selecting rescue tx: Consider abx susceptibility, pt’s age, & avail. abx options;1 avoid abx used in initial tx
- Consider repeat endoscopy: Use results to tailor tx x14 days1
- Explain to family the importance of adherence to selected regimen1
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx;1 younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15min prior to meals
- Adolescents: May consider tetracycline or levofloxacin as part of the regimen,1 though dosing in adolescents for H. pylori infection is not defined
- Do not replace tetracycline w/ doxycycline;2 doxycycline is not as effective as tetracycline for H. pylori infections
- PCN allergy: Tx options for pts initially tx w/ metronidazole and clarithromycin are not defined1,3-4
- A study in adults suggests incr acid suppression & metronidazole dose may improve eradiation;5 higher doses of PPI & metronidazole may be considered in children,1 although dosing is not defined
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk1
Drug links | Antimicrobials Drug links | Acid suppressive Tx Footnotes 1 Jones NL, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017. Jun;64(6):991-1003. Free full-text article PDF
2 Liou JM, et al. Efficacies of Genotypic Resistance-Guided vs Empirical Therapy for Refractory Helicobacter pylori Infection. Gastroenterology. 2018 Oct;155(4):1109-1119. PubMed® abstract
3 Jun JS, et al. Changes in the Treatment Strategies for Helicobacter pylori Infection in Children and Adolescents in Korea. Pediatr Gastroenterol Hepatol Nutr. 2019. Sep;22(5):417-430. PubMed® abstract | Free full-text article PDF @ PubMed® Central
4 Aguilera Matos I, et al. Helicobacter pylori Infection in Children. BMJ Paediatr Open. 2020. Aug 3;4(1):e000679. PubMed® abstract | Free full-text article PDF @ PubMed®
5 Molina-Infante J, et al. Optimised Empiric Triple and Concomitant Therapy for Helicobacter pylori Eradication in Clinical Practice: The OPTRICON Study. Aliment Pharmacol Ther. 2015. Mar;41(6):581–589. PubMed® abstract H. pylori initially resistant to clarithromycin and metronidazole After a 1st-failure, individualize tx based on abx susceptibility, pt age, & abx options for at least 14 days1 - When selecting rescue tx: Tx options are not defined; consider abx susceptibility, pt’s age, & avail. abx options;1 avoid abx used in initial tx
- Explain to family the importance of adherence to selected regimen1
- Evidence is lacking to support the efficacy of rescue tx in pediatric pts w/ dual resistance to clarithromycin & metronidazole vs adults1
- A study in adults suggests incr acid suppression and metronidazole dose may improve eradication;2 higher doses of PPI & metronidazole may be considered in children,1 although dosing is not defined
- Do not replace tetracycline w/ doxycycline;4 doxycycline is not as effective as tetracycline for H. pylori infections
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx;1 younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15mins prior to meals
- PCN allergy: Tx options are not defined1,5-6
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk1
Footnotes 1 Jones NL, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017. Jun;64(6):991-1003. Free full-text article PDF
2 Molina-Infante J, et al. Optimised Empiric Triple and Concomitant Therapy for Helicobacter pylori Eradication in Clinical Practice: The OPTRICON Study. Aliment Pharmacol Ther. 2015. Mar;41(6):581–589. PubMed® abstract
3 Delchier JC, et al. Use of a Combination Formulation of Bismuth, Metronidazole and Tetracycline With Omeprazole as a Rescue Therapy for Eradication of Helicobacter pylori. Aliment Pharmacol Ther. 2014. Jul;40(2):171-177. PubMed® abstract
4 Liou JM, et al. Efficacies of Genotypic Resistance-Guided vs Empirical Therapy for Refractory Helicobacter pylori Infection. Gastroenterology. 2018 Oct;155(4):1109-1119. PubMed® abstract
5 Jun JS, et al. Changes in the Treatment Strategies for Helicobacter pylori Infection in Children and Adolescents in Korea. Pediatr Gastroenterol Hepatol Nutr. 2019. Sep;22(5):417-430. PubMed® abstract | Free full-text article PDF @ PubMed® Central
6 Aguilera Matos I, et al. Helicobacter pylori Infection in Children. BMJ Paediatr Open. 2020. Aug 3;4(1):e000679. PubMed® abstract | Free full-text article PDF @ PubMed®
H. pylori initial susceptibility unknown Pt weight 15-24 kg: Rescue tx regimens Pt weight 25-34 kg: Rescue tx regimens Pt weight >35 kg: Rescue tx regimens After a 1st-failure, tx for at least 14 days1 - When selecting rescue tx: Consider abx susceptibility, pt’s age, & avail. abx options;1 avoid abx used in initial tx
- Consider repeat endoscopy: Use results to tailor tx x14 days1
- Explain to family the importance of adherence to selected regimen1
- PPI: A higher degree of acid suppression improves success of amoxicillin & clarithromycin-based tx;1 younger children need a higher PPI dose/kg to obtain sufficient acid suppression vs adolescents & adults; esomeprazole & rabeprazole may be preferred due to decr susceptibility to degradation in pts who are rapid metabolizers of CYP2C19; rapid metabolizers are more frequently of Caucasian ancestry (56%-81%) vs Asian ancestry; give PPI 15mins prior to meals
- Adolescents: May consider tetracycline or levofloxacin as part of the regimen,1 although dosing in adolescents for H. pylori infection is not defined
- Do not replace tetracycline w/ doxycycline;2 doxycycline is not as effective as tetracycline for H. pylori infections
- PCN allergy: Tx options for pts initially tx w/ metronidazole and clarithromycin are not defined1,3-4
- A study in adults suggests incr acid suppression & metronidazole dose may improve eradiation;5 higher doses of PPI & metronidazole may be considered in children,1 although dosing is not defined
- Test success of eradication tx: Use urea breath test or fecal antigen test ≥4wk after tx completion and after withholding acid suppression tx x2wk1
Drug links | Antimicrobials Drug links | Acid suppressive Tx Footnotes 1 Jones NL, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017. Jun;64(6):991-1003. Free full-text article PDF
2 Liou JM, et al. Efficacies of Genotypic Resistance-Guided vs Empirical Therapy for Refractory Helicobacter pylori Infection. Gastroenterology. 2018 Oct;155(4):1109-1119. PubMed® abstract
3 Jun JS, et al. Changes in the Treatment Strategies for Helicobacter pylori Infection in Children and Adolescents in Korea. Pediatr Gastroenterol Hepatol Nutr. 2019. Sep;22(5):417-430. PubMed® abstract | Free full-text article PDF @ PubMed® Central
4 Aguilera Matos I, et al. Helicobacter pylori Infection in Children. BMJ Paediatr Open. 2020. Aug 3;4(1):e000679. PubMed® abstract | Free full-text article PDF @ PubMed®
5 Molina-Infante J, et al. Optimised Empiric Triple and Concomitant Therapy for Helicobacter pylori Eradication in Clinical Practice: The OPTRICON Study. Aliment Pharmacol Ther. 2015. Mar;41(6):581–589. PubMed® abstract
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