American College of Gastroenterology Clinical Guideline
Antibiotic Selection
There is increased resistance to clarithromycin, and traditional triple therapy (clarithromycin + amoxicillin + proton pump inhibitors [PPIs]) should not be prescribed unless the rates of clarithromycin resistance are known to be < 15%.
We should not use clarithromycin triple therapy.
Then what to use as First-Line Therapy
Quadruple therapy: Clarithromycin (500 mg), amoxicillin (1 g), metronidazole (500 mg), and a PPI, all given twice a day.
Or bismuth subsalicylate (2 tablets four times a day), metronidazole (500 mg three or four times a day), tetracycline (500 mg four times a day), and a PPI (twice a day). Patients on this regimen will need to be informed about bismuth-related stool darkening.
Or Triple therapy with levofloxacin (500 mg once a day), amoxicillin (1 g twice a day), and a PPI (twice a day) is an alternative but not recommended as the best initial option.
Treatment Duration
Recommendation is 14 days
Salvage Therapy for Persistent H pylori Infection
Avoid antibiotics previously used
Bismuth-based quadruple therapy or levofloxacin triple therapy are accepted salvage regimens.
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