Helicobacter pylori

Background

Slow-growing Gram-negative microaerophilic bacillus with a curve, gull-wing, or spiral appearance
Oxidase-positive and urease-positive
Major cause of peptic ulcer disease and gastric cancer

Treatment is with combination therapy for 14 days followed by confirmation of eradication
First-line:
- PBMT (PPI, bismuth, metronidazole, tetracycline) (BMT Quad)
- PAMC (PPI, amoxicillin, metronidazole, clarithromycin) (CLAMET Quad)
- PAC (PPI, amoxicillin, clarithromycin), PMC (PPI, metronidazole, clarithromycin), or PAM (PPI, amoxicillin, metronidazole) only in areas with clarithromycin resistance <15% or with proven high local eradication rates >85%
Prior treatment failure:
- PBMT (PPI, bismuth, metronidazole, tetracycline)
- PAL (PPI, amoxicillin, levofloxacin)
- PAR (PPI, amoxicillin, rifabutin) for 10 days, as last-line
Doses:
- PBMT
  - Bismuth subsalicylate 524 mg (2x 262 mg tablets) PO qid
  - Metronidazole 500 MG PO tid or qid
  - PPI: esomeprazole 20 mg, lansoprazole 30 mg, omeprazole 20 mg, pantoprazole 40 mg, or rabeprazole 20 mg
    - Some areas use double dosing
  - Tetracycline 500 mg PO qid
- Others
  - Amoxicillin 1000 mg PO bid
  - Clarithromycin 500 mg PO bid
  - Levofloxacin 500 mg PO daily
  - Metronidazole 500 mg PO bid
  - Rifabutin 150 mg PO bid
  - PPI as above
Duration: 14 days
Confirmation of eradication should be done 4 weeks following treatment
Recommended order of treatment, if persistently positive:
- PBMT (or PAMC)
- PAMC (or PBMT)
- PAL
- PAR vs. repeat endoscopy for culture and susceptibility testing

H. pylori Enhanced Primary Care Pathway: 2016 version, 2019 version, 2020 version
The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterol. 2016;151:51–69. doi: 10.1053/j.gastro.2016.04.006
Houston Consensus Conference on Testing for Helicobacter pylori Infection in the United States. Clin Gastroenterol Hepatol. 2018;16(7):992-1002.e6. doi: 10.1016/j.cgh.2018.03.013