H. Pylori Infection Treatments

H. PYLORI INFECTION TREATMENTS
Allergy Previous macrolide exposure1 No previous macrolide exposure
RECOMMENDATIONS
Penicillin • Bismuth quadruple

• Clarithromycin triple with metronidazole

• Bismuth quadruple

No penicillin allergy

• Bismuth quadruple

• Alternative regimens3

• Bismuth quadruple

• Clarithromycin triple with amoxicillin

• Concomitant2

• Alternative regimens3

FIRST-LINE REGIMENS3
Regimen Drugs/Dosing Duration (days)
Clarithromycin triple4,5

• PPI (standard or double dose twice daily) PLUS

• clarithromycin (500mg twice daily) PLUS

• amoxicillin (1g twice daily) OR
metronidazole (500mg three times daily)

14
Bismuth quadruple6

• PPI (standard dose twice daily) PLUS

• bismuth subcitrate (120–300mg 4 times daily) or subsalicylate (300mg 4 times daily) PLUS

• tetracycline (500mg 4 times daily) PLUS

• metronidazole (250mg 4 times daily or 500mg 3–4 times daily)

10–14
Concomitant2,7

• PPI (standard dose twice daily) PLUS

• clarithromycin (500mg twice daily) PLUS

• amoxicillin (1g twice daily) PLUS

• metronidazole or tinidazole (500mg twice daily)

10–14
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 Not an FDA-approved regimen.

3 For suggested alternative regimens that are not FDA-approved (eg, sequential, hybrid, levofloxacin triple or sequential, and LOAD), please consult ACG’s H. pylori infection clinical guideline.

4 Several PPIs (eg, Prilosec, Nexium, Prevacid, Aciphex) in combination with clarithromycin and amoxicillin have achieved FDA approval. PPI + clarithromycin + metronidazole is not an FDA-approved regimen.

5 Clarithromycin triple therapy should be avoided if clarithromycin resistance is >15%.

6 Not an FDA-approved regimen if prescribed separately. Pylera (bismuth subcitrate/tetracycline/metronidazole) combined with omeprazole for 10 days is FDA-approved.

7 First-line option for patients with intolerance to bismuth.

 

For FDA-approved regimens, see drug monographs at www.eMPR.com or contact company for full drug labeling.

REFERENCE

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. 1/2023)