Treatment of Helicobacter pylori Infection

Publication Date: September 4, 2024
Last Updated: September 4, 2024

Summary of Recommendations

In treatment-naive patients with H. pylori infection, optimized BQT is recommended as a first-line treatment option.

(S, M )
620
In treatment-naive patients with H. pylori infection, rifabutin triple therapy is suggested as a first-line treatment option. (C, L )
620
In treatment-naive patients with H. pylori infection, dual therapy with a PCAB and amoxicillin is suggested as a first-line treatment option. (C, M )
620
In treatment-naive patients with H. pylori infection and unknown clarithromycin susceptibility, PCAB-clarithromycin triple therapy is suggested over PPI-clarithromycin triple therapy. (C, M )
620
In treatment-naive patients with H. pylori infection, concomitant therapy is not suggested over BQT. (C, L )
620
In treatment-experienced patients with persistent H. pylori infection who have not previously received BQT, optimized BQT is suggested. (C, VL )
620
In treatment-experienced patients with persistent H. pylori infection who have previously received PPI-clarithromycin triple therapy, optimized BQT is suggested. (C, L )
620

In treatment-experienced patients with persistent H. pylori infection who have received BQT, rifabutin triple therapy is suggested.

(C, L )
620
In treatment-experienced patients with persistent H. pylori infection who have not previously received optimized BQT, optimized BQT is suggested over quinolone-based therapy. (C, L )
620
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. (C, L )
620
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. (no recommendation - evidence gap) (U, U)
620
There is insufficient evidence to suggest that the use of probiotic therapy improves the efficacy or tolerability of H. pylori eradication therapy. (C, L )
620

Recommendation Grading

Overview

Title

Treatment of Helicobacter pylori Infection

Authoring Organization

American College of Gastroenterology

Publication Month/Year

September 4, 2024

Last Updated Month/Year

September 9, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Helicobacter pylori is a prevalent, global infectious disease that causes dyspepsia, peptic ulcer disease, and gastric cancer. The American College of Gastroenterology commissioned this clinical practice guideline (CPG) to inform the evidence-based management of patients with H. pylori infection in North America. This CPG used Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology to systematically analyze 11 Population, Intervention, Comparison, and Outcome questions and generate recommendations. Where evidence was insufficient or the topic did not lend itself to GRADE, expert consensus was used to create 6 key concepts. For treatment-naive patients with H. pylori infection, bismuth quadruple therapy (BQT) for 14 days is the preferred regimen when antibiotic susceptibility is unknown. Rifabutin triple therapy or potassium-competitive acid blocker dual therapy for 14 days is a suitable empiric alternative in patients without penicillin allergy. In treatment-experienced patients with persistent H. pylori infection, “optimized” BQT for 14 days is preferred for those who have not been treated with optimized BQT previously and for whom antibiotic susceptibility is unknown. In patients previously treated with optimized BQT, rifabutin triple therapy for 14 days is a suitable empiric alternative. Salvage regimens containing clarithromycin or levofloxacin should only be used if antibiotic susceptibility is confirmed. The CPG also addresses who to test, the need for universal post-treatment test-of-cure, and the current evidence regarding antibiotic susceptibility testing and its role in guiding the choice of initial and salvage treatment. The CPG concludes with a discussion of proposed research priorities to address knowledge gaps and inform future management recommendations in patients with H. pylori infection from North America.

Target Patient Population

Patients with H. Pylori infection

Inclusion Criteria

Male, Female, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Long term care, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D019072 - Antibiotic Prophylaxis, D016998 - Helicobacter, D041981 - Gastrointestinal Tract, D016480 - Helicobacter pylori

Keywords

infection, dyspepsia, Helicobacter pylori, gastrointestinal, H.pylori

Source Citation

Chey, William D. MD, FACG1; Howden, Colin W. MD, FACG2; Moss, Steven F. MD, FACG3; Morgan, Douglas R. MD, MPH, FACG4; Greer, Katarina B. MD, MSEpi5; Grover, Shilpa MD, MPH6; Shah, Shailja C. MD, MPH7. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. The American Journal of Gastroenterology 119(9):p 1730-1753, September 2024. | DOI: 10.14309/ajg.0000000000002968

Supplemental Methodology Resources

Data Supplement, Data Supplement