You have treated a patient with triple therapy and confirmation of cure with stool antigen or breath test comes back showing that the patient is still positive. What do you do?
- About 20% of H. pylori treatment fails after initial treatment.
- Make sure that the patient is compliant with medications.
- Since the patient has failed an initial course of treatment, we will use an alternate regimen (triple or quadruple therapy) using a different combination of antibiotics for 14 days.
- We won’t use Clarithromycin unless we have cultures that show that this H. pylori strain is susceptible to Clarithromycin.
- Will avoid antibiotics that have been used before.
- Will consider culture with antibiotic sensitivity testing to guide subsequent treatments if the patient fails the second antibiotic combination.
- Rx: omeprazole (20 mg BID), tetracycline (500 mg BID), metronidazole (500 mg BID), and bismuth subcitrate caplets (240 mg BID), each given twice daily with the midday and evening meals for 14 days
- Rx: Florastor to prevent C-diff.
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Recommended regimens for patients who have failed treatment.
- Levofloxacin (250 mg), amoxicillin (1 g), and a PPI each given twice daily for 14 days.
- Omeprazole (20 mg), tetracycline (500 mg), metronidazole (500 mg), and bismuth subcitrate caplets (240 mg), each given twice daily with the midday and evening meals for 14 days has been shown to result in a 95% eradication rate.
- Reserve rifabutin-containing regimens for patients with ≥2 previous antibiotic failures. The regimen is rifabutin (150 mg), amoxicillin (1 g), bismuth subsalicylate/subcitrate, and a PPI each given twice daily for 14 days.
American College of Gastroenterology first-line H. pylori regimens (adult dosing, oral administration) – Table from Uptodate.com
| Patients who are not allergic to penicillin and have not previously received a macrolide | Standard dose PPI* twice daily (or esomeprazole 40 mg once daily) plus clarithromycin 500 mg twice daily, and amoxicillin 1000 mg twice daily for 10-14 days¶ |
| Patients who are allergic to penicillin, and who have not previously received a macrolide or metronidazole or are unable to tolerate bismuth quadruple therapy | Standard dose PPI twice daily, clarithromycin 500 mg twice daily, metronidazole 500 mg twice daily for 10-14 days¶ |
| Patients who are allergic to penicillin or failed one course (above) of H. pylori treatment | Bismuth subsalicylate 525 mg four times daily, metronidazole 250 mg four times daily, tetracycline 500 mg four times daily, standard dose PPI* twice daily for 10-14 daysΔ
OR Bismuth subcitrate 420 mg four times daily, metronidazole 375 mg four times daily, tetracycline 375 mg four times daily◊, standard dose PPI* twice daily for 10-14 daysΔ |
Resources:
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744171/
- http://www.aafp.org/afp/2015/0215/p236.html
- https://www.uptodate.com/contents/treatment-regimens-for-helicobacter-pylori
- https://www.ncbi.nlm.nih.gov/pubmed/17608775