The updated guide is available online and will appear in the March print issue of MIMS.
Testing for H. pylori
Before starting eradication treatment, the presence of H.pylori should be confirmed using a carbon-13 urea breath test, stool antigen test or locally validated laboratory-based serology.
First-line H. pylori treatment
Patients who test positive for H. pylori should begin with a 7-day, twice-daily triple-therapy regimen comprising a proton pump inhibitor (PPI), amoxicillin, and either clarithromycin or metronidazole. Healthcare professionals should take into account previous exposure to clarithromycin or metronidazole and choose the treatment regimen with the lowest acquisition cost. If the patient has a penicillin allergy, a combination of a PPI, clarithromycin and metronidazole is advised.
The above regimens eradicate H. pylori in about 85% of cases. Treatment failure can indicate poor compliance or antibacterial resistance.
Second-line treatment of H. pylori
Patients who still have symptoms after first-line eradication treatment should receive a 7-day, twice-daily course of treatment with a PPI, amoxicillin and either clarithromycin or metronidazole (whichever was not used first-line). A quinolone or tetracycline (whichever has the lowest acquisition cost) should be used if the patient has previous exposure to clarithromycin and metronidazole.
If a patient is allergic to penicillin and has not previously been treated with a quinolone, a PPI should be given with metronidazole and levofloxacin.
Quadruple H. pylori therapy with bismuth
If a patient with penicillin allergy requires first-line treatment and has already received clarithromycin, or requires second-line treatment and has already received a quinolone, combining a PPI with bismuth, metronidazole and tetracycline is recommended. This regimen is not included in the MIMS summary, however, following the recent discontinuation of De-Noltab (tri-potassium di-citrato bismuthate), the only bismuth product for which there is UK clinical experience in this setting.