Helicobacter Pylori (H. Pylori)

Helicobacter pylori (H. pylori) Testing for H. pylori  Patients with the following conditions should be tested for infection with H. pylori: o Active peptic ulcer disease (PUD) o Past history of PUD (unless previous cure of H. pylori infection has been documented) o Low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma o History of endoscopic resection of early gastric cancer (EGC) o In whom chronic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) are being initiated o Unexplained iron deficiency anemia despite an appropriate evaluation o Idiopathic thrombocytopenic purpura (ITP) o Dyspepsia and are undergoing upper endoscopy (tested via gastric biopsies)  Consider testing in the following scenarios: o Uninvestigated dyspepsia in patients who are under the age of 60 and without alarm features (via non-endoscopic testing) o Patients taking long-term, low-dose aspirin to reduce risk of ulcer bleeding  There is insufficient evidence to support routine testing in the following: o Patients with typical symptoms of gastroesophageal reflux disease who do not have a history of PUD o Asymptomatic individuals with a family history of gastric cancer o Patients with lymphocytic gastritis, hyperplasic gastric polyps, and hyperemesis gravidarum Treatment  All patients with a positive H. pylori test should be offered treatment  Quadruple therapy (see table below) is recommended in most patients Regimen Antibiotics Pantoprazole 40 mg PO twice daily PLUS Bismuth subsalicylate 525 mg PO four times daily Quadruple PLUS therapy Metronidazole 250 mg PO four times daily PLUS Tetracycline 500 mg PO four times daily  Triple therapy (see table below) remains a recommended treatment option: o for patients without previous exposure to macrolides o in areas where clarithromycin resistance is known to be < 15%^ Regimen Antibiotics Pantoprazole 40 mg PO twice daily PLUS Triple Clarithromycin 500 mg PO twice daily therapy PLUS Amoxicillin 1000 mg PO twice daily* Duration 10 – 14 days Duration 14 days *substitute metronidazole 500 mg three times daily if penicillin allergy ^Clarithromycin resistance rates for H. pylori at BMC are unknown, but assumed to be >15%  There is a limited role for IV antibiotics for the treatment of H. pylori. Treatment should be delayed until a patient is able to tolerate oral antibiotics. If IV antibiotics are necessary, please contact the antibiotic stewardship team. Salvage Regimens In patients with persistent infection, a salvage regimen (see options in table below) should be selected that utilizes different antibiotics than their previous regimen  Clarithromycin- or levofloxacin-containing salvage regimens are the preferred treatment options if they received bismuth quadruple therapy as their first regimen Regimen Antibiotics Duration Pantoprazole 40 mg PO twice daily PLUS Levofloxacin triple Levofloxacin 500 mg daily 14 days regimen PLUS Amoxicillin 1000 mg PO twice daily** Pantoprazole 40 mg PO twice daily PLUS MacrolideClarithromycin 500 mg PO twice daily Nitroimidazole PLUS 10-14 days Concomitant Amoxicillin 1000 mg PO twice daily** Regimen PLUS Metronidazole 500 mg PO three times daily **Penicillin allergic patients should be evaluated for skin testing for consideration of amoxicillin-containing salvage regimens  Bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options if their first regimen contained clarithromycin Regimen Antibiotics Duration Pantoprazole 40 mg PO twice daily PLUS Bismuth Bismuth subsalicylate 525 mg PO four times daily quadruple PLUS 14 days regimen Metronidazole 250 mg PO four times daily PLUS Tetracycline 500 mg PO four times daily