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TREATMENT
The ACG’s 2007 treatment guideline on the management of H. pylori infection (26) listed the following as established indications for diagnosis and treatment:
===Indications===
*Active PUD (gastric or duodenal).
*Confirmed history of PUD (not previously treated for H. pylori)
*Gastric MALT lymphoma (low grade)
*After endoscopic resection of EGC
 
Recommended  first-line treatment for Helicobacter pylori


{| class="wikitable"
{| class="wikitable"
Line 15: Line 22:
|BID
|BID
|14 days
|14 days
|YES
|YES<sup>†</sup>
|-
|-
|Bismuth Quadruple
|Bismuth Quadruple
Line 31: Line 38:
TID to QID (500mg)  
TID to QID (500mg)  
|10-14 days  
|10-14 days  
|NO
|NO<sup>‡</sup>
|-
|-
|Concomitant
|Concomitant
Line 58: Line 65:
|PPI(standard)+Amoxicillin(1gm)
|PPI(standard)+Amoxicillin(1gm)
PPI,Amoxicillin,Clarithromycin(500mg),Nitroimidazole(500mg)
PPI,Amoxicillin,Clarithromycin(500mg),Nitroimidazole(500mg)
|
|BID
|
BID
|
|7 days
7 days
|NO
|-
|-
|
|Levofloxacin triple
|
|PPI(standard dose)
|
Levofloxacin(500mg)
|
 
|
Amoxicillin(1gm)
|BID
QID
 
BID
 
|10-14 days
|NO
|-
|Levofloxacin sequential
|PPI(standard or double dose)+Amoxicillin(1 gm)
PPI,Amoxicillin,Levofloxacin(500mg QD),Nitroimidazole(500mg)
|BID
BID
|5-7 days
|NO
|-
|-
|
|LOAD
|
|Levofloxacin(250mg)
|
PPI(double dose)
|
 
|
Nitazoxanide(500mg)
 
Doxycycline(100mg)
|QD
QD
 
BID
 
QD
|7-10 days
|NO
|}
|}
'''†''': Several PPI, Clarithromycin, and Amoxicillin combinations have achieved FDA approval ,PPI, Clarithromycin, Metronidazole is not an FDA approved treatment regimen.
'''‡:''' PPI, Bismuth, Tetracycline and metronidazole prescribed separately is not an FDA approved treatment regimen.However ,Pylera, a combination product containing Bismuth subcitrate,Tetracycline , Metronidazole combination with PPi for 10 days is an FDA approved regimen.
'''Adjuvant therapy in the treatment of H. pylori infection:'''
Emerging evidence suggests an inhibitory effect of Lactobacillus
and Bifidobacterium species on H. pylori. Furthermore,
these probiotic strains may also help to reduce the side effects
of eradication therapies and improve compliance with therapy.
== Selection of firstline Treatment==
{{familytree/start}}
{{familytree |boxstyle=text-align: left; | | | | | | | | | A01 | | | |A01=•Is there a penicillin (PCN) allergy?<br> •Previous macrolide (MCL) exposure for any reason ?<br>}}
{{familytree | | |,|-|-|-|-|v|-|^|-|v|-|-|-|.| ||}} 
{{familytree |boxstyle=text-align: left; | | B01 | | | B02 | | B03 | | B04||B01=•PCN allergy: '''No'''<br> •MCL exposure: '''No'''<br> |B02=•PCN allergy: '''No'''<br> •MCL exposure: '''Yes'''<br> |B03=•PCN allergy: '''Yes'''<br> •MCL exposure: '''No'''<br> |B04=•PCN allergy: '''Yes'''<br> •MCL exposure: '''Yes'''<br> }}
{{familytree | | |!| | | | |!| | | |!| | | |!| ||}} 
{{familytree |boxstyle=text-align: left; | | B01 | | | B02 | | B03 | | B04||B01='''Recomended treatment:'''<br> •Bismuth quadruple <br> •Clarithromycin triple with amoxicillin<br> '''Other options''':<br> •Sequential<br> •HYBRID<br> •Levofloxacin triple<br> •Levofloxacin sequential <br>•LOAD<br> |B02='''Recomended treatment:'''<br>•Bismuth quadruple <br>•Levofloxacin sequential<br>'''Other options''':<br>•Concomitant therapy<br>•Sequential therapy <br>• HYBRID<br> •LOAD<br>|B03='''Recomended treatment:'''<br> •Bismuth quadruple <br> •Clarithromycin triple <br> with metronidazole<br> •Bismuth quadruple<br>|B04= '''Recomended treatment:''' <br> •Bismuth quadruple <br> •Clarithromycin triple with metronidazole<br> •Bismuth quadruple<br>}}
{{Familytree/end}}
{{familytree/start}}
{{familytree| | | | | | | | | | | | | | | | | | A01 | | | | | |A01=Persistent Helicobacter pylori infection }}
{{familytree| | | | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| |}}
{{familytree| | | | | | | | | B01 | | | | | | | | | | | | | | | | B02 ||B01=Patient recieved clarithromycin triple therapy|B02=Patient received Bismuth quadriple therapy }}
{{familytree| | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.|}}
{{familytree|boxstyle=text-align: left; | C01 | | C02 | | | | C03 | | C04 | | C05 | | C06 | | | | C07 | | C08 | |C01= •No previous Quinolone exposure<br>•No PCN allergy<br>'''Recomended treatment:'''<br> •Bismuth quadruple<br> •Levofloxacin<br> •Rifabutin triple<br> •High dose dual|C02= •Previous Quinolone exposure<br> •No PCN Allergy<br>'''Recomended treatment:'''<br> •Bismuth quadruple therapy<br> •Rifabutin triple<br> •High dose dual<br>|C03= •No previous Quinolone exposure<br> •PCN Allergy<br> '''Recomended treatment:'''<br>•Bismuth quadruple| C04=•Previous Quinolone exposure<br> •PCN Allergy<br>'''Recomended treatment:'''<br> •Bismuth quadruple<br>|C05=•No previous Quinolone exposure<br>•No PCN allergy<br>'''Recomended treatment:'''<br>•Levofloxacin triple concomitant<br>•Rifabutin triple<br>•High dose triple<br>|C06=•Previous Quinolone exposure<br> •No PCN Allergy<br>'''Recomended treatment:'''<br>•Concomitant Rifabutin triple <br>•High dose dual<br>|C07=•No previous Quinolone<br> exposure<br> •PCN Allergy<br> '''Recomended treatment:'''<br>•PPI,Clarithromycin<br>,Metronidazole<br>•PPI,Levofloxacin,<br>Metronidazole|C08=•Previous Quinolone exposure<br> •No PCN Allergy<br>'''Recomended treatment:'''<br> •PPI,Clarithromycin,<br>Metronidazole<br>•Bismuth quadruple }}
{{familytree/end}}
===Diagnostic testing===
The American Journal of Gastroenterology guidelines recommend that '''endoscopy''' should be performed to rule out [[peptic ulcer disease]], esophagogastric [[malignancy]], and other rare upper gastrointestinal tract disease in the following settings:
* [[Dyspeptic]] patients <u>more than 55 years old</u> {{or2}}
* [[Dyspeptic]] patients with <u>alarm features</u>
:* [[Bleeding]]
:* [[Anemia]]
:* [[Early satiety]]
:* Unexplained [[weight loss]] (> 10% body weight)
:* Progressive [[dysphagia]]
:* [[Odynophagia]]
:* Persistent [[vomiting]]
:* A family history of gastrointestinal cancer
:* Previous esophagogastric [[malignancy]]
:* Previous documented [[peptic ulcer]], [[lymphadenopathy]], or an abdominal mass
In patients aged 55 years or younger with no alarm features, two management options may be considered:
* '''Test-and-treat strategy''' using a validated noninvasive test (urea breathing test or stool antigen test) for ''[[H. pylori]]'' and a trial of acid suppression if eradication is successful but symptoms do not resolve – preferable in populations with a moderate to high prevalence of ''[[H. pylori]]'' infection (≥ 10%)
* '''Empiric trial of acid suppression''' with a [[proton pump inhibitor]] for 4–8 weeks – preferable in low prevalence situations
Repeat [[endoscopy]] is not recommended once a firm diagnosis of functional [[dyspepsia]] has been established, unless new symptoms or alarm features develop.<ref>{{Cite journal| doi = 10.1111/j.1572-0241.2005.00225.x| issn = 0002-9270| volume = 100| issue = 10| pages = 2324–2337| last1 = Talley| first1 = Nicholas J.| last2 = Vakil| first2 = Nimish| last3 = Practice Parameters Committee of the American College of Gastroenterology| title = Guidelines for the management of dyspepsia| journal = The American Journal of Gastroenterology| date = 2005-10| pmid = 16181387}}</ref>  Testing to prove ''[[H. pylori]]'' eradication is most accurate if performed 4 weeks after the completion of therapy.<ref>{{Cite journal| doi = 10.1136/gutjnl-2012-302084| issn = 1468-3288| volume = 61| issue = 5| pages = 646–664| last1 = Malfertheiner| first1 = Peter| last2 = Megraud| first2 = Francis| last3 = O'Morain| first3 = Colm A.| last4 = Atherton| first4 = John| last5 = Axon| first5 = Anthony T. R.| last6 = Bazzoli| first6 = Franco| last7 = Gensini| first7 = Gian Franco| last8 = Gisbert| first8 = Javier P.| last9 = Graham| first9 = David Y.| last10 = Rokkas| first10 = Theodore| last11 = El-Omar| first11 = Emad M.| last12 = Kuipers| first12 = Ernst J.| last13 = European Helicobacter Study Group| title = Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report| journal = Gut| date = 2012-05| pmid = 22491499}}</ref>

Latest revision as of 14:48, 30 October 2017

The ACG’s 2007 treatment guideline on the management of H. pylori infection (26) listed the following as established indications for diagnosis and treatment:

Indications

  • Active PUD (gastric or duodenal).
  • Confirmed history of PUD (not previously treated for H. pylori)
  • Gastric MALT lymphoma (low grade)
  • After endoscopic resection of EGC

Recommended first-line treatment for Helicobacter pylori

Regimen Drug dose Dosing frequency Duration(days) FDA approval
Clarithromycin triple PPI(standard or double dose

Clarithromycin(500mg)

Amoxicillin(1gm)or Metronidazole(500mg TID)

BID 14 days YES
Bismuth Quadruple PPI(standard dose)

Bismuth subcitrate (120-300mg)or Subsalicylate (300mg)

Tetracyclin(500mg)

Metronidazole(250-500mg)

BID

QID

QID

TID to QID (500mg)

10-14 days NO
Concomitant PPI (standard dose)

Clarithromycin (500mg)

Amoxicillin(1gm)

Nitroimidazole(500mg)

BID 10 -14 days NO
Sequential PPI(standard dose)+Amoxicillin(1gm)

PPI,Clarithromycin(500mg)+Nitroimidazole(500mg)

BID

BID

5-7 days

5-7 days

NO
Hybrid PPI(standard)+Amoxicillin(1gm)

PPI,Amoxicillin,Clarithromycin(500mg),Nitroimidazole(500mg)

BID

BID

7 days

7 days

NO
Levofloxacin triple PPI(standard dose)

Levofloxacin(500mg)

Amoxicillin(1gm)

BID

QID

BID

10-14 days NO
Levofloxacin sequential PPI(standard or double dose)+Amoxicillin(1 gm)

PPI,Amoxicillin,Levofloxacin(500mg QD),Nitroimidazole(500mg)

BID

BID

5-7 days NO
LOAD Levofloxacin(250mg)

PPI(double dose)

Nitazoxanide(500mg)

Doxycycline(100mg)

QD

QD

BID

QD

7-10 days NO

: Several PPI, Clarithromycin, and Amoxicillin combinations have achieved FDA approval ,PPI, Clarithromycin, Metronidazole is not an FDA approved treatment regimen.

‡: PPI, Bismuth, Tetracycline and metronidazole prescribed separately is not an FDA approved treatment regimen.However ,Pylera, a combination product containing Bismuth subcitrate,Tetracycline , Metronidazole combination with PPi for 10 days is an FDA approved regimen.

Adjuvant therapy in the treatment of H. pylori infection:

Emerging evidence suggests an inhibitory effect of Lactobacillus and Bifidobacterium species on H. pylori. Furthermore, these probiotic strains may also help to reduce the side effects of eradication therapies and improve compliance with therapy.

Selection of firstline Treatment

 
 
 
 
 
 
 
 
•Is there a penicillin (PCN) allergy?
•Previous macrolide (MCL) exposure for any reason ?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
•PCN allergy: No
•MCL exposure: No
 
 
•PCN allergy: No
•MCL exposure: Yes
 
•PCN allergy: Yes
•MCL exposure: No
 
•PCN allergy: Yes
•MCL exposure: Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recomended treatment:
•Bismuth quadruple
•Clarithromycin triple with amoxicillin
Other options:
•Sequential
•HYBRID
•Levofloxacin triple
•Levofloxacin sequential
•LOAD
 
 
Recomended treatment:
•Bismuth quadruple
•Levofloxacin sequential
Other options:
•Concomitant therapy
•Sequential therapy
• HYBRID
•LOAD
 
Recomended treatment:
•Bismuth quadruple
•Clarithromycin triple
with metronidazole
•Bismuth quadruple
 
Recomended treatment:
•Bismuth quadruple
•Clarithromycin triple with metronidazole
•Bismuth quadruple


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Persistent Helicobacter pylori infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient recieved clarithromycin triple therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient received Bismuth quadriple therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
•No previous Quinolone exposure
•No PCN allergy
Recomended treatment:
•Bismuth quadruple
•Levofloxacin
•Rifabutin triple
•High dose dual
 
•Previous Quinolone exposure
•No PCN Allergy
Recomended treatment:
•Bismuth quadruple therapy
•Rifabutin triple
•High dose dual
 
 
 
•No previous Quinolone exposure
•PCN Allergy
Recomended treatment:
•Bismuth quadruple
 
•Previous Quinolone exposure
•PCN Allergy
Recomended treatment:
•Bismuth quadruple
 
•No previous Quinolone exposure
•No PCN allergy
Recomended treatment:
•Levofloxacin triple concomitant
•Rifabutin triple
•High dose triple
 
•Previous Quinolone exposure
•No PCN Allergy
Recomended treatment:
•Concomitant Rifabutin triple
•High dose dual
 
 
 
•No previous Quinolone
exposure
•PCN Allergy
Recomended treatment:
•PPI,Clarithromycin
,Metronidazole
•PPI,Levofloxacin,
Metronidazole
 
•Previous Quinolone exposure
•No PCN Allergy
Recomended treatment:
•PPI,Clarithromycin,
Metronidazole
•Bismuth quadruple
 


Diagnostic testing

The American Journal of Gastroenterology guidelines recommend that endoscopy should be performed to rule out peptic ulcer disease, esophagogastric malignancy, and other rare upper gastrointestinal tract disease in the following settings:

In patients aged 55 years or younger with no alarm features, two management options may be considered:

  • Test-and-treat strategy using a validated noninvasive test (urea breathing test or stool antigen test) for H. pylori and a trial of acid suppression if eradication is successful but symptoms do not resolve – preferable in populations with a moderate to high prevalence of H. pylori infection (≥ 10%)
  • Empiric trial of acid suppression with a proton pump inhibitor for 4–8 weeks – preferable in low prevalence situations

Repeat endoscopy is not recommended once a firm diagnosis of functional dyspepsia has been established, unless new symptoms or alarm features develop.[1] Testing to prove H. pylori eradication is most accurate if performed 4 weeks after the completion of therapy.[2]

  1. Talley, Nicholas J.; Vakil, Nimish; Practice Parameters Committee of the American College of Gastroenterology (2005-10). "Guidelines for the management of dyspepsia". The American Journal of Gastroenterology. 100 (10): 2324–2337. doi:10.1111/j.1572-0241.2005.00225.x. ISSN 0002-9270. PMID 16181387. Check date values in: |date= (help)
  2. Malfertheiner, Peter; Megraud, Francis; O'Morain, Colm A.; Atherton, John; Axon, Anthony T. R.; Bazzoli, Franco; Gensini, Gian Franco; Gisbert, Javier P.; Graham, David Y.; Rokkas, Theodore; El-Omar, Emad M.; Kuipers, Ernst J.; European Helicobacter Study Group (2012-05). "Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report". Gut. 61 (5): 646–664. doi:10.1136/gutjnl-2012-302084. ISSN 1468-3288. PMID 22491499. Check date values in: |date= (help)