Sandbox/guillermo

Principles of Eradication Therapy for Helicobacter pylori infection

1. Indications for diagnosis and treatment, established:
   1. Active peptic ulcer disease.
   2. Confirmed history of peptic ulcer disease not previously treated for H. pylori.
   3. Gastric MALT lymphoma.
   4. After endoscopic resection of early gastric cancer.
   5. Uninvestigated dyspepsia (review H. pylori prevalence).
2. Low clarithromycin resistance areas (<15%):
   1. In areas of low resistance the PPI-clarithromycin-containing triple therapy is recommended as the first-line treatment as well as bismuth-containing quadruple therapy.
   2. In areas of low resistance after failure of a PPI-clarithromycin-containing treatment, either a bismuth-containing quadruple therapy or levofloxacin-containing triple therapy is recommended.
3. High clarithromycin resistance areas (≥15%):
   1. In areas of high resistance, bismuth-containing quadruple therapy are recommended for first-line treatment.
   2. In areas of high resistance after failure of bismuth containing quadruple therapy, levofloxacin containing triple therapy is recommended.
4. After failure of second-line treatment, treatment should be guided by antimicrobial susceptibility testing.
5. FDA PPI standard doses:
   1. Lansoprazole 30 mg q12h.
   2. Omeprazole 20 mg q12h.
   3. Esomeprazole 40 mg q24h.
   4. Rabeprazole 20 mg q12h.
6. FDA approved first line regimens duration:
   1. Triple therapy: 7 days (10 days if rabeprazole).
   2. Quadruple therapy: 4 weeks.
7. Confirm the eradication of H. pylori infection in patients who have had an H. pylori-associated ulcer or gastric MALT lymphoma or who have undergone resection for early gastric cancer.
8. The urea breathing test is the most reliable nonendoscopic test to document eradication of H. pylori infection.
9. Testing to prove H. pylori eradication is most accurate if performed at 4 weeks after the completion of eradication therapy.

Countries with a reported prevalence <15% of H. pylori resistance to clarithromycin

Europe	North America	South America	Middle East	Far East
Bulgaria (8.7%) Croatia (8%) Germany (2.2–4%) Italy (North) (1.8%) Netherlands (1.7%) Spain (12.9%) Sweden (2.9%) UK (3.9–4.4%)	Canada (12%) USA (10.6–12.2%)†	Brazil (9.8%)	Israel (8.2%) Saudi Arabia (4%)	China (14%) Hong Kong (4.5%) Korea (14%) New Zealand (11%)

^† There is a reported prevalence of 15% in the Northeast of the US.

Countries with a reported prevalence ≥15% of H. pylori resistance to clarithromycin

Europe	North America	Middle East	Far East
France (15%) Italy (central) (23.4%) Portugal (22%)	Mexico (25%)	Iran (17%)	India (33%) Japan (15%)

Helicobacter pylori Eradication Therapies

▸ Click on the following categories to expand treatment regimens.

First line   ▸  Triple therapy   ▸  Quadruple therapy Second line   ▸  Triple therapy   ▸  Sequential therapy   ▸  Hybrid therapy Third line therapy (Rescue therapy)   ▸  Rifabutin based

Triple therapy ▸ Lansoprazole 30 mg q12h OR ▸ Omeprazole 20 mg q12h OR ▸ Esomeprazole 40 mg q24h OR ▸ Rabeprazole 20 mg q12h PLUS ▸ Clarithromycin 500 mg q12h. PLUS ▸ Amoxicillin 1 g q12h Quadruple therapy ▸ Bismuth subsalicylate 525 mg orally q6h PLUS ▸ Metronidazol 250 mg orally q6h PLUS ▸ Tetracycline 500 mg orally q6h PLUS ▸ Ranitidine 150 mg orally q12h OR ▸ PPI standard dose Triple therapy ▸ Lansoprazole 30 mg q12h OR ▸ Omeprazole 20 mg q12h OR ▸ Esomeprazole 40 mg q24h OR ▸ Rabeprazole 20 mg q12h PLUS ▸ Clarithromycin 500 mg q12h PLUS ▸ Metronidazole 500 mg q12h Sequential therapy First 5 days ▸ Lansoprazole 30 mg q12h OR ▸ Omeprazole 20 mg q12h OR ▸ Esomeprazole 40 mg q24h OR ▸ Rabeprazole 20 mg q12h PLUS ▸ Amoxicillin 1 g q12h Next 5 days ▸ Lansoprazole 30 mg q12h OR ▸ Omeprazole 20 mg q12h OR ▸ Esomeprazole 40 mg q24h OR ▸ Rabeprazole 20 mg q12h PLUS ▸ Clarithromycin 500 mg q12h PLUS ▸ Tinidazol 500 mg q12h Sequential therapy First 7 days ▸ Lansoprazole 30 mg q12h OR ▸ Omeprazole 20 mg q12h OR ▸ Esomeprazole 40 mg q24h OR ▸ Rabeprazole 20 mg q12h PLUS ▸ Amoxicillin 1 g q12h Next 7 days ▸ PPI standard dose PLUS ▸ Amoxicillin 1 g q12h PLUS ▸ Clarithromycin 500 mg q12h PLUS ▸ Metronidazol 500 mg q12h Third line treatment ▸ Rifabutin 150 mg q2h PLUS ▸ Amoxicillin 1 g IV q12h PLUS ▸ Ciprofloxacin 500 mg/kg IV q12h