Helicobacter Pylori infection management guidelines .pdf

Clinical pharmacy

1. Helicobacter Pylori
New Recommendations… Will
Practice Change ??
Presented by
Mohamed Rawy
Clinical Pharmacist , BSc , BCPS , BCCCP

2. Talk outline
-Definition
-Clinical Manifestations
-Pathophysiology
-Diagnosis
-Management
-Monitoring

3. Definition
-Helicobacter pylori is a gram-negative bacterium that colonizes the
human gastric mucosa and invariably causes gastritis, which may
progress to overt gastroduodenal disease
-It is the most common chronic bacterial infection in humans and the
most common cause of infection-associated cancer
-It is associated with peptic ulcer disease, chronic gastritis, gastric
adenocarcinoma, and gastric mucosa-associated lymphoid tissue
lymphoma

4. Clinical Manifestations
•Stomach pain
•Heartburn
•Sensation of a full stomach
•Decreased appetite
•Dyspepsia
•Belching & Nausea
•Bad taste in the mouth
•Increased bleeding gums

5. Pathophysiology
H. pylori predominantly colonizes the gastric mucosa and is
uniquely adapted to survive in the stomach's harsh acidic
environment
The pathophysiology and clinical manifestations of H. pylori
infection involve a complex relationship between the host
and the bacteriumthat includes the interplay of bacterial
colonization, persistence, and virulence and the ensuing host
immune response
This interaction is influenced by various environmental and
host factors, some of which remain unidentified

6. Pathophysiology
Bacterial factors
Adherence
Enzyme release
Virulence factors
CagA and VacA
virulence factors
Host factors
T cell response
IL-8 and other cytokines

7. Pathophysiology

Complications of
infection with
H.Pylori bacteria:
1.Gastrointestinal
2.Extra-gastric

8. Diagnosis
1.When to test ??
• H. pylori testing should only occur in clinical situations where
treatment of H. pylori will be offered if the test is positive
•The choice of test used to diagnose H. pylori depends on whether a
patient requires an upper endoscopy for evaluation of upper
gastrointestinal (GI) symptoms or surveillance
•Endoscopy is not indicated solely for the purpose of establishing H.
pylori status

9. Diagnosis
-In patients who do not require endoscopic evaluation, noninvasive,
non-serologic testing with urea breath testing (UBT) or stool antigen
assay is the test of choice to evaluate for active H. pylori infection ,
Both are accurate and easy to perform
- The choice between these tests depends on local availability and
patient preference
-PPI & PCAB should be stopped 2 weeks before performing non
serologic tests to avoid false negative results
-for patients who are on PPIs or PCABs switch to H2RA or antacids like
calcium carbonate (they do not impact H. pylori test performance)
-Guidelines from the American College of Gastroenterology
recommend against routine serologic testing

10. Diagnosis
-UBT is an accurate, noninvasive test that utilizes the hydrolysis of urea
by H. pylori to detect H. pylori infection
•UBT has sensitivity & specificity of 95%
-Stool antigen assay use monoclonal antibodies to detect specific H.
pylori antigens, which indicate active infection
•Stool antigen assay has sensitivity & specificity of 93-96%
-Limitations of serology testing
•They do not distinguish between active and past infection
•Serology is also less accurate than UBT and stool antigen assays
•Demonstrates a low positive predictive value in low-prevalence
populations

11. Diagnosis
-Patient undergoing upper endoscopy:
•Check if there is active bleeding peptic ulcer
Without Active Bleeding
Histology (preferred)
Rapid Urease Testing (Alternative)
Culture (not routinely used , only if
antimicrobial susceptibility testing)
With Active Bleeding
- Perform gastric biopsies for H.
pylori detection during the initial
endoscopy unless there is
insufficient time to do so because
of patient instability
- Alternatively, H. pylori serology
provides rapid results that can
guide the decision of H. pylori
treatment in these patients

12. Diagnosis
Indications for H.Pylori testing

13. Diagnosis
H. pylori detection methods can be divided into invasive and non-
invasive examinations
Non invasive examinations
Urea breath test (UBT)
Stool antigen test (SAT)
Serological
Invasive examinations
Endoscopy

14. Management
Pretreatment considerations …
1.Whom to treat ??
•All patients who test positive for active H. pylori infection (ie, have a
positive non-serologic test) should be offered treatment

15. Management
Pretreatment considerations …
ACG Clinical Guideline (2024)
Treatment of Helicobacter pylori Infection
Guideline summary points

16. Management
How to select initial regimen ??
-In treatment-naive patients with H. pylori infection, optimized BQTis
recommended as a first-line treatment option
-In treatment-naive patients with H. pylori infection, rifabutin triple
therapy is suggested as a first-line treatment option
-In treatment-naive patients with H. pylori infection, dual therapy
with PCAB + amoxicillin is suggested as a first-line treatment option
-In treatment-naive patients with H. pylori infection and unknown
clarithromycin susceptibility, PCAB-clarithromycin triple therapy is
suggested over PPI-clarithromycin triple therapy if no alternative
first-line therapy is available
-In treatment-naive patients with H. pylori infection, concomitant
therapy is not suggested over bismuth quadruple therapy

17. Management
How to select initial regimen ??
-In treatment-experienced patients with persistent H. pylori infection
who have not previously received bismuth quadruple therapy,
optimized bismuth quadruple therapy is suggested
-In treatment-experienced patients with persistent H. pylori infection
who have previously received PPI-clarithromycin triple therapy,
optimized bismuth quadruple therapy is suggested
-In treatment-experienced patients with persistent H. pylori infection
who have received bismuth quadruple therapy, rifabutin triple
therapy is suggested
-In treatment-experienced patients with persistent H. pylori infection
who have not previously received optimized bismuth quadruple
therapy, optimized bismuth quadruple therapy is suggested over
quinolone-based therapy

18. Management
How to select initial regimen ??
-In treatment-experienced patients with persistent H. pylori infection,
levofloxacin triple therapy is suggested in patients with known
levofloxacin-sensitive H. pylori strains and when optimized bismuth
quadruple or rifabutin triple therapies have previously been used or
are unavailable
-In treatment-experienced patients with persistent H. pylori infection
that is confirmed to be clarithromycin-sensitive, PPI- or PCAB-
clarithromycin triple therapy is suggested
-In treatment-experienced patients with persistent H. pylori infection,
there is insufficient evidence from North America to recommend
high-dose PPI or PCAB dual therapy

19. Management
How to select initial regimen ??
-The determination of when to test for—and treat—H. pylori should be
viewed as a single, rather than 2 separate and distinct, decisions
-Clarithromycin- and levofloxacin-containing treatment regimens should be
avoided in the absence of demonstrated macrolide and quinolone
susceptibility
-H. pylori antibiotic susceptibility tests using either phenotypic (culture-
based) or molecular methods (polymerase chain reaction or next-
generation sequencing) are becoming increasingly available in the US
-All patients who are treated for H. pylori infection should undergo a test of
cure with an appropriately conducted urea breath test, fecal antigen test,
or biopsy based test at least 4 weeks after completion of therapy
-There is insufficient evidence to suggest that the use of probiotic therapy
improves the efficacy or tolerability of H. pylori eradication therapy

20. Management

21. Management
How to select initial regimen ??

22. Management
How to select initial regimen ??

23. Management
Recommended regimens for “treatment-naïve” patients with H. pylori infection

24. Management
How to select initial regimen ??
-Optimized BQT is the preferred option for empiric first-line therapy
-Consider local antibiotic resistance patterns and rates of H. pylori
eradication; the patient's previous antibiotic exposures, allergies,
medication intolerances, and possible drug-drug interactions;
regimen cost; and ease of administration
-Although combination medication capsules simplify pill regimens,
they are expensive, and payors may not cover them

25. Management
How to select initial regimen ??
Optimized BQT is the preferred option for empiric first-line therapy
-It is the preferred regimen in areas with high or unknown rates of H.
pylori resistance to clarithromycin and can be used in patients with
and without penicillin allergy
-Alternative regimens are:
Low-dose rifabutin triple therapy OR Vonoprazan dual therapy OR
Vonoprazan triple therapy
Avoid empiric treatment containing clarithromycin or levofloxacin
•Regimens that include clarithromycin or levofloxacin should only be
used in patients whose H. pylori strains demonstrate susceptibility to
these antibiotics based on antimicrobial susceptibility testing

26. Management
How to select initial regimen ??
Optimized BQT is the preferred option for empiric first-line therapy
-It is the preferred regimen in areas with high or unknown rates of H.
pylori resistance to clarithromycin and can be used in patients with and
without penicillin allergy (Eradication of infection in ~ 85% of cases)
-It consists of a 10 to 14 day treatment course that includes a proton pump
inhibitor (PPI) twice daily, high doses of bismuth subsalicylate, tetracycline,
and metronidazole 500 mg three or four times daily
-BQT = Pylera® (or Heldac®) + PPI
-Clinicians should not substitute doxycycline for tetracycline because this
significantly decreases rates of treatment success
-Appropriate metronidazole dosing (1.5 to 2 g total daily dose) and the
addition of sufficiently dosed bismuth are typically sufficient to overcome
in vitro metronidazole resistance
-Patients with a salicylate allergy should take Pylera, which contains
bismuth subcitrate, rather than bismuth subsalicylate

27. Management
How to select initial regimen ??
Optimized BQT is the preferred option for empiric first-line therapy
-Regimen is 3 tablets of (Bismuth + Tetracycline + Metronidazole) QID
after food in combination with omeprazole 20mg BID for 10 days
-Taken after a meal while seated with a full glass of water (250 ml),
particularly with the bedtime dose, to reduce the risk of oesophageal
ulceration by tetracycline hydrochloride , Patients should not lay
down immediately after Pylera and omeprazole intake
-Capsule should be swallowed whole , Not to be opened or crushed
-Avoid use in pediatrics less than 12 years & not recommended in
children from 12-18 years of age
-Avoid use in pregnancy or breastfeeding
-Avoid use in severe Hepatic or Renal impairment

28. Management
How to select initial regimen ??
Optimized BQT is the preferred option for empiric first-line therapy
Pylera ® (Bismuth 140mg + Tetracycline 125mg + Metronidazole 125mg) QID
after food in combination with omeprazole 20mg BID for 10 days

29. Management
How to select initial regimen ??
Optimized BQT is the preferred option for empiric first-line therapy
-Combination pills are simpler to take but likely more expensive than
BQT component therapy (ie, using the four medications prescribed
separately)
-We prefer Pylera or component antibiotic therapy to Helidac
because Helidac only delivers 1 g of metronidazole daily
-Although optimized BQT has not been directly compared with low-
dose rifabutin triple therapy or vonoprazan-based regimens, it is
highly effective for H. pylori eradication in "real-world" populations,
including the United States

30. Management
How to select initial regimen ??
Optimized BQT is the preferred option for empiric first-line therapy

31. Management
How to select initial regimen ??
Optimized BQT is the preferred option for empiric first-line therapy
-Common side effects include diarrhea, nausea, metallic taste, and
black tongue and/or stool
-Although all H. pylori regimens cause side effects, these may be more
common with BQT
-Patients have difficulty complying with this regimen because of its
complexity (4 medications taken up to 4 times per day while
obtaining tablets from 4 different pill bottles)
-Vonoprazan-amoxicillin dual therapy (bubble packaging) had lower
rates of side effects than BQT
-We counsel patients to expect side effects and provide anticipatory
guidance and medications to treat symptoms if needed (eg,
ondansetron for nausea)

32. Management
How to select initial regimen ??
Rational for Empiric treatment …
-We prefer an empiric treatment approach for the management of
treatment-naïve patients rather than performing antimicrobial
susceptibility testing if the local H. pylori eradication rate with
optimized BQT is ≥85 %
-Empiric treatment with BQT appears comparable to selecting a
regimen based on the results of antimicrobial susceptibility

33. Management
How to select initial regimen ??
Alternative regimens to QBT …
1.Low-dose rifabutin triple therapy
2.Vonoprazan dual therapy
3.Vonoprazan triple therapy
-They are alternative first-line treatment regimens for treatment-
naïve individuals with H. pylori infection, especially if local eradication
rates with optimized BQT are < 85%

34. Management
How to select initial regimen ??
Alternative regimens to QBT …
1.Low-dose Rifabutin triple therapy
TALICIA ®

35. Management
How to select initial regimen ??
Alternative regimens to QBT …
1.Low-dose Rifabutin triple therapy
-Reserve for select patients in whom optimized BTQ is not an option
especially if local eradication rates with optimized BQT are <85%
-Low-dose Rifabutin triple therapy demonstrates high rates of H. pylori
eradication, and its dosing schedule may be easier to take than that
of BQT , However , it is expensive
-It is FDA – Approved
-Rifabutin is a World Health Organization (WHO) watchlist antibiotic,
meaning that it should be used cautiously and monitored to avoid
overuse and preserve its effectiveness

36. Management
How to select initial regimen ??
Alternative regimens to QBT …
1.Low-dose Rifabutin triple therapy
-Dosing & Administration:
-Regimen: Rifabutin 12.5mg , Amoxicillin 250mg , Omeprazole 10mg
-Dosing is to administer 4 capsules TID for after meals for 14 days
-Swallow whole , Do not open , chew or crush capsule
-Avoid use in patients with sever hepatic or renal impairment
-Avoid use in patients less than 18 years of age
-Avoid in those with mononucleosis
-Not recommended in pregnancy
-Discontinue if hypersensitivity or severe cutaneous reactions, or drug-
induced enterocolitis syndrome occurs or if acute tubulointerstitial
nephritis is suspected, or if symptoms consistent with cutaneous or
systemic lupus erythematosus

37. Management
How to select initial regimen ??
Alternative regimens to QBT …
1.Low-dose Rifabutin triple therapy
-Pharmacokinetic studies indicate that using rifabutin “ Low dose ”
50 mg three times daily achieves the most consistent intragastric
concentrations, compared with other dosing schedules (ie, 150 mg or
300 mg once daily or 150 mg twice daily)
-We assess patients for potential drug-drug interactions before
initiating rifabutin
-In countries where tuberculosis is endemic, rifabutin is a less
preferred option given its WHO watchlist status and theoretical
potential to induce cross-resistance to rifampin. However, rifampin
cross-resistance has not been substantiated with the short duration
of rifabutin used in H. pylori therapy

38. Management
How to select initial regimen ??
Alternative regimens to QBT …
1.Low-dose Rifabutin triple therapy
-Efficacy: Although the comparative efficacy between rifabutin triple
therapy and BQT has not been studied, low-dose rifabutin triple
therapy demonstrates high efficacy and is superior to dual therapy
with amoxicillin plus a PPI

39. Management
How to select initial regimen ??
Alternative regimens to QBT …
2. Vonoprazan containing regimens
-Vonoprazan-based regimens offer a lower pill burden and less complex
regimen compared with BQT and, possibly fewer side effects
-However, these regimens have not been directly compared with optimized
BQT, may have lower efficacy than optimized BQT
-Recommended duration of initialH. pyloritreatment regimens is 14 days
-Twovonoprazan-based regimens are FDA-approved combination pills for
first-line therapy:
•Dual therapy (Voquezna Dual Pak®) … vonoprazan-amoxicillin
•Triple therapy (Voquezna Triple Pak®) … vonoprazan-amoxicillin-
clarithromycin

40. Management
How to select initial regimen ??
Alternative regimens to QBT …
2. Vonoprazan containing regimens

41. Management
How to select initial regimen ??
Alternative regimens to QBT …
2. Vonoprazan containing regimens
-In the United States and other countries with high rates of
clarithromycin resistance, we reserve vonoprazan triple therapy for
scenarios where clarithromycin susceptibility is confirmed
-Vonoprazan is a potassium-competitive acid blocker (PCAB) , which
produce more rapid and potent acid suppression than that achieved
with lansoprazole and possibly other PPIs
-Unlike PPIs, PCABs can be taken with or without food without
impacting efficacy

42. Management
How to select initial regimen ??
Alternative regimens to QBT …
2. Vonoprazan containing regimens
-Efficacy – Vonoprazan-based regimens appear superior to PPI-based
regimens
-Vonoprazan-amoxicillin (dual therapy) appears to have comparable
efficacy for H. pylori eradication compared with vonoprazan-
amoxicillin-clarithromycin (triple therapy)

43. Management
Duration of therapy ??
-The recommended duration of initial H. pylori treatment regimens is
14 days, except for the fixed-dose combination pill Pylera, which is a
10-day regimen
-Treatment courses that are less than 10 days are not recommended

44. Management
Ensuring treatment success ??
1.Pretreatment counseling
2.Attention to resistance patterns
3.Gastric acid suppression

45. Management
Ensuring treatment success ??
-Pretreatment counseling …
•We counsel patients thatH. pylorieradication is associated with peptic
ulcer healing, reduces the likelihood of ulcer recurrence, reduces the risk of
gastric cancer, and, in symptomatic individuals, may improve or resolve
dyspepsia symptoms.
•We emphasize that completing the entire treatment course and not
skipping medication doses maximizes the chance ofH. pylorieradication
and avoids the need for salvage treatment, which is generally associated
with lower rates of eradication success
•We also inform patients about the appropriate timing and administration
of medications and their expected side effects
•We discuss common side effects, such as a black tongue and/or stool with
bismuth and gastrointestinal upset with antibiotics.
•We encourage patients to notify us if they are unable to tolerate treatment
due to side effects and provide medications to treat side effects

46. Management
Ensuring treatment success ??
-Attention to resistance patterns …
•Clinicians should develop an awareness of local H. pylori resistance
patterns , Although initial treatment for H. pylori is usually empiric,
clinicians should use pretreatment antimicrobial susceptibility
information if available

47. Management
Ensuring treatment success ??
-Gastric acid suppression …
•Regimens to treat H. pylori should include an agent that achieves and
maintains potent gastric acid suppression, specifically a PPI or PCAB
•Adequate, sustained gastric acid suppression may enhance the
efficacy of some antibiotics (Ex. Amoxicillin & Clarithromycin)
•To achieve this, we prescribe a PPI twice daily 30 minutes prior to
meals or PCAB twice daily which can be dosed independent of
mealtime
•We prefer higher-potency second-generation PPIs, such as
Esomeprazole or Rabeprazole, and avoid the lower-potency first-
generation PPIs (Omeprazole, Lansoprazole, Pantoprazole) if possible

48. Management
Ensuring treatment success ??
-Gastric acid suppression …
•CYP2C19 metabolizer status:
•CYP2C19 metabolizer status can affect gastric acid suppression and the
likelihood of H. pylori eradication when first-generation PPIs (omeprazole,
lansoprazole, and pantoprazole) are used
•Extensive (rapid or ultrarapid) metabolizers typically have lower plasma
concentrations of these medications
•Eradication failure was independent of CYP2C19 phenotype in patients
who were given the second-generation PPIs rabeprazole or esomeprazole,
which either bypass or are not heavily metabolized by CYP2C19
•Individuals with known CYP2C19 extensive metabolizer status receive
esomeprazole or rabeprazole or, if given omeprazole, lansoprazole, or
pantoprazole, have the dose increased by 50 to 100 percent

49. Management
Treatment Failure ??
-Rates of treatment failure with the use of clarithromycin- or
levofloxacin-based regimens are higher in populations where local H.
pylori resistance rates to these antibiotics >15%
-The most common causes of H. pylori treatment failure include:
•Antibiotic resistance of the patient's H. pylori strain
•Treatment non-adherence
•Insufficient dosing or frequency of prescribed medications
•Inadequate gastric acid suppression

50. Management
Treatment Failure ??
-Selecting a regimen for salvage therapy …
-"Salvage" therapy refers to any regimen used to treat persistent H.
pylori infection following an initial treatment course that failed
-Because persistent, or "refractory," infection places patients at
ongoing risk of H. pylori-related complications, all those with
persistent infection should receive treatment
-Specific measures in the setting of persistent H. pylori infection
include:
1.Selecting a different treatment regimen
2.Optimized acid suppression
3.Antimicrobial susceptibility testing (For selected patients)

51. Management
Treatment Failure ??
-Key considerationsin selecting a regimen for salvage therapy …
1.Select a different regimen
- In individuals with persistent H. pylori infection, we use an
alternative therapeutic regimen with a different combination of
antibiotics than the patient previously took
-Patients who received bismuth quadruple therapy (BQT) that was
not optimized (eg, insufficient dose of metronidazole or substitution
of doxycycline for tetracycline) should receive optimized BQT
-Salvage therapy should not include clarithromycin or levofloxacin
unless antibiotic susceptibility testing demonstrates H. pylori
susceptibility to these antibiotics

52. Management
Treatment Failure ??
-Key considerationsin selecting a regimen for salvage therapy …
- Select a different regimen …. Prior treatment with a single regimen
-In patients with persistent H. pylori infection after a single round of
treatment , salvage regimens are similar to those used in treatment-
naïve patients and include:
1. Optimized BQT
2. Rifabutin triple therapy
3. Vonoprazan-amoxicillin dual regimens

53. Management
Treatment Failure ??
-Key considerationsin selecting a regimen for salvage therapy …
- Select a different regimen …. No prior bismuth quadruple therapy
-Individuals who have not previously received a BQT regimen should
receive optimized BQT
-Optimized BQT consists of a 14-day treatment course that includes a
PPI twice daily, high doses of bismuth subsalicylate, tetracycline, and
metronidazole 500 mg three or four times daily
-Pylera ® plus a twice-daily PPI for 10 days can also be used in these
patients (efficacyas a 2
nd
line therapy is 89%)

54. Management
Treatment Failure ??
-Key considerationsin selecting a regimen for salvage therapy …
- Select a different regimen …. Prior bismuth quadruple therapy
•Patients who took "suboptimal" BQT
-In patients who previously took BQT, we evaluate whether they
received a lower-than-recommended dose of metronidazole (<1.5 g
daily) or doxycycline as a substitute for tetracycline
-If either of these conditions are met, the patient should undergo
retreatment with optimized BQT

55. Management
Treatment Failure ??
-Key considerationsin selecting a regimen for salvage therapy …
-Select a different regimen …. Patients who took optimized BQT
Without PCN allergy:
1.Rifabutin triple therapy,
2.Vonoprazan-amoxicillin dual therapy
3.High-dose PPI dual therapy
- Few clinical data exist to guide regimen
selection in these patients However, each of
these regimens includes high-potency acid
suppression, and resistance to rifabutin
andamoxicillinrarely exists in the United States
With PCN allergy:
- It is important to confirm the presence of a
true penicillin allergy
- Do allergy testing to confirm allergy from PCN
- In most cases, penicillin allergy can be delisted
& amoxicillin-containing regimen can be used
- In patients with a true penicillin allergy, we
suggest antimicrobial susceptibility testing to
inform regimen selection
-ADVDAV
-AVDVD

56. Management
Treatment Failure ??
-Key considerationsin selecting a regimen for salvage therapy …
-Prior treatment with more than one regimen
-In patients with H. pylori infection that persists after two distinct
courses of treatment, we suggest selecting a regimen that is tailored
to the results of antimicrobial susceptibility testing
-An alternative approach consists of empiric treatment based on the
patient's prior H. pylori treatment regimens and past antibiotic
exposures, allergies, and intolerances. Ideally, regimen selection
should occur in consultation with a gastroenterologist experienced
in treating H. pylori

57. Management
Treatment Failure ??
-Key considerationsin selecting a regimen for salvage therapy …
-Specific regimens:
-Antimicrobial susceptibility testing enables clinicians to select
regimens containing clarithromycin and levofloxacin for patients
whose H. pylori strains are susceptible to these antibiotics in addition
to other salvage regimens
-We only use regimens with clarithromycin or levofloxacin when the
H. pylori strain has known susceptibility since H. pylori resistance to
macrolides and fluoroquinolones is common

58. Management
Treatment Failure ??
-Key considerationsin selecting a regimen for salvage therapy …
-Specific regimens:
1.Clarithromycin triple therapy (Classic regimen .. Only if sensitive)
2.Levofloxacin triple therapy (Last Resort .. only if sensitive)
3.Metronidazole triple therapy (if sensitive to metronidazole)
4.Other regimens:
-Various combination regimens that include clarithromycin and/or
levofloxacin and/or amoxicillin and acid-suppressive medications have
been studied outside of the United States
-They include "hybrid," "sequential," "concomitant," and "reverse hybrid"
regimens and have generally been used in first-line therapy
-These have not been widely studied in the United States, and their
complex dosing instructions may undermine patient adherence

59. Management
Treatment Failure ??
-Key considerationsin selecting a regimen for salvage therapy …
Goal Plan
Sequential
Weaken the bacterial wall by amoxicillin
making bacteria more sensitive to another
antibiotics in 2
nd
phase
Days 1–5: PPI (e.g., omeprazole) + amoxicillin
Days 6–10: PPI + clarithromycin +
metronidazole (or tinidazole)
Concomitant
Attack the bacteria from multiple angles at
once, increasing the chance of eradication
Day 1-14: PPI + amoxicillin + clarithromycin +
metronidazole (or tinidazole)
Hybrid
Similar to sequential therapy, but the second
phase adds all antibiotics while continuing
amoxicillin
Days 1–7: PPI + amoxicillin
Days 8–14: PPI + amoxicillin + clarithromycin
+ metronidazole (or tinidazole)
Reverse Hybrid
Start aggressively with triple antibiotics, then
continue with just amoxicillin to clean up
remaining bacteria
Days 1–7: PPI + amoxicillin + clarithromycin +
metronidazole (concomitant phase first)
Days 8–14: PPI + amoxicillin only

60. Management
Treatment Failure ??
-Key considerationsin selecting a regimen for salvage therapy …
2. Optimize acid suppression
- To ensure that insufficient gastric acid suppression is not a factor, we
typically use high-dose proton pump inhibitors (PPIs; double the
standard dose twice daily), more potent PPIs (eg, esomeprazole or
rabeprazole), or vonoprazan, especially with regimens that contain
antibiotics that are more prone to the effects of gastric acid (eg,
amoxicillin and clarithromycin)
-Thrice-daily high-dose PPI options (eg, omeprazole 40 mg thrice daily
or esomeprazole 40 mg thrice daily) can be used in amoxicillin-
containing salvage therapy regimens (eg, rifabutin triple therapy and
high-dose PPI dual therapy)

61. Management
Treatment Failure ??
Salvage regimens for persistent H. pylori infection

62. Management
Treatment Failure ??

63. Management
Treatment Failure ??

64. Management
Recommended regimens for “treatment-experienced” patients with “persistent” H. pylori infection

65. Management
Role of Probiotics ??
-Probiotics may have an inhibitory effect on H. pylori and may reduce
antibiotic side effects, thereby potentially improving patients' ability
to adhere to the full treatment course
-However , there is insufficient evidence to suggest that the use of
probiotic therapy improves the efficacy or tolerability of H. pylori
eradication therapy

66. Management
What if pregnancy or breastfeeding ??
- In pregnant persons with H. pylori infection, we defer treatment of H.
pylori until after delivery and breastfeeding are completed because
most antimicrobials used to treat H. pylori (eg, bismuth, metronidazole,
and levofloxacin) are contraindicated in pregnancy and nursing

67. Monitoring
Confirmation of eradication ??
-Test of cure should be performed at least four weeks after H. pylori
treatment completion and at least two weeks after stopping acid
suppression medications (eg, proton pump inhibitors or potassium-
competitive acid blockers)
-Although these drugs can lead to false-negative results on histology,
urea breath testing, and urease testing, their impact on the accuracy
of stool H. pylori antigen is less clear
-Patients with symptoms of dyspepsia or reflux can take histamine 2
receptor antagonists and antacids (eg, calcium carbonate) because
these do not significantly impact the sensitivity of nonserologic H.
pylori diagnostic tests

68. Monitoring
Confirmation of eradication ??
-Diagnostic options for confirming eradication include:
•Urea breath test
•Fecal antigen test
•Biopsy during upper endoscopy
- The choice of test is similar to that for individuals undergoing initial
testing for H. pylori and depends on the need for an upper endoscopy
(eg, follow-up of bleeding peptic ulcer) and local availability. H. pylori
serologic tests are not appropriate diagnostic tests of cure because
serology does not reliably distinguish between active and past infection
and antibody levels do not fall predictably following successful
eradication

69. References …
-ACG Clinical Guideline: Treatment of Helicobacter pylori
Infection 2025
-Up To Date
-Lexi comp

70. Thank You ☺
You can find me at
[email protected]
Mohamed Rawy
Mohamed Rawy (Roma)