Treatment of H. pylori Infection : American College of Gastroenterology Guideline

American College of Gastroenterology has released H Pylori new treatment consensus Clinical Guideline.

Helicobacter pylori (H. pylori) infection is a common worldwide infection that is an important cause of peptic ulcer disease and gastric cancer. In addition to this H. pylori may also have a role in uninvestigated and functional dyspepsia, ulcer risk in patients taking aspirin or a non-steroidal anti-inflammatory medication, unexplained iron deficiency anaemia, and idiopathic thrombocytopenic purpura.

It is very important that while choosing a treatment regimen for H. pylori, patients should be asked about previous antibiotic exposure and this information should be incorporated into the decision-making process.

Major Recommendations :

• Patients should be asked about any previous antibiotic exposure(s) and this information should be taken into consideration when choosing an H. pylori treatment regimen (conditional recommendation, moderate quality of evidence).


• Clarithromycin triple therapy consisting of a PPI, clarithromycin, and amoxicillin or metronidazole for 14 days remains a recommended treatment option in regions where H. pylori clarithromycin resistance is known to be <15% and in patients with no previous history of macrolide exposure for any reason (conditional recommendation, low quality of evidence (for duration: moderate quality of evidence)).


• Bismuth quadruple therapy consisting of a PPI, bismuth, tetracycline, and a nitroimidazole for 10–14 days is a recommended first-line treatment option. Bismuth quadruple therapy is particularly attractive in patients with any previous macrolide exposure or who are allergic to penicillin (strong recommendation, low quality of evidence).


• Concomitant therapy consisting of a PPI, clarithromycin, amoxicillin and a nitroimidazole for 10–14 days is a recommended first-line treatment option (Strong recommendation, low quality of evidence (for duration: very low quality of evidence)).


• Sequential therapy consisting of a PPI and amoxicillin for 5–7 days followed by a PPI, clarithromycin, and a nitroimidazole for 5–7 days is a suggested first-line treatment option (conditional recommendation, low quality of evidence (for duration: very low quality of evidence).


• Hybrid therapy consisting of a PPI and amoxicillin for 7 days followed by a PPI, amoxicillin, clarithromycin and a nitroimidazole for 7 days is a suggested first-line treatment option (conditional recommendation, low quality of evidence (For duration: very low quality of evidence)).


• Levofloxacin triple therapy consisting of a PPI, levofloxacin, and amoxicillin for 10–14 days is a suggested first-line treatment option (conditional recommendation, low quality of evidence (for duration: very low quality of evidence)).


• Fluoroquinolone sequential therapy consisting of a PPI and amoxicillin for 5–7 days followed by a PPI, fluoroquinolone, and nitroimidazole for 5–7 days is a suggested first-line treatment option (conditional recommendation, low quality of evidence (For duration: very low quality of evidence)


• When first-line therapy fails, a salvage regimen should avoid antibiotics that were previously used. Bismuth-based quadruple therapy or levofloxacin triple therapy are accepted salvage regimens.