Red Flags
- H. pylori with active or recent peptic ulcer bleeding — admit; PPI infusion plus eradication once stabilised[1]
- Gastric MALT lymphoma diagnosis — eradicate H. pylori; many regress without chemotherapy[1]
- Family history of gastric cancer plus H. pylori — eradicate; surveillance endoscopy if dysplasia/atrophy[1]
- Persistent H. pylori after first-line eradication — high resistance burden; switch class, do not repeat clarithromycin[1]
First-line treatment
Interventions
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Bismuth quadruple therapy (BQT)[1] | PPI + bismuth + tetracycline + metronidazole | PPI BD + bismuth subcitrate 120 mg QID + tetracycline 500 mg QID + metronidazole 500 mg QID — 14 days | — | First-line per ACG 2024 in regions of high clarithromycin resistance (>15%); India falls in this category |
| Concomitant non-bismuth quadruple therapy[1] | PPI + amoxicillin + clarithromycin + metronidazole | PPI BD + amoxicillin 1 g BD + clarithromycin 500 mg BD + metronidazole 500 mg BD — 14 days | Per weight per ESPGHAN paediatric guideline | Alternative first-line; only use where clarithromycin resistance <15% |
| Vonoprazan-based dual therapy[1] | Potassium-competitive acid blocker + amoxicillin | Vonoprazan 20 mg BD + amoxicillin 1 g TID — 14 days | — | Newer first-line option per VOQUEZNA-CAB; superior acid suppression than PPI; emerging data for clarithromycin-resistant strains |
| Levofloxacin triple (salvage)[1] | Salvage regimen | PPI BD + amoxicillin 1 g BD + levofloxacin 500 mg daily — 10–14 days | — | Second-line salvage when initial therapy fails; do NOT use clarithromycin in retreatment |
| Rifabutin-containing rescue regimen[1] | Rescue therapy | PPI BD + amoxicillin 1 g BD + rifabutin 150 mg BD — 14 days | — | Refractory H. pylori after multiple eradication failures; specialist |
Bismuth quadruple therapy (BQT)[1]
PPI + bismuth + tetracycline + metronidazole
- Adult
- PPI BD + bismuth subcitrate 120 mg QID + tetracycline 500 mg QID + metronidazole 500 mg QID — 14 days
- Paediatric
- —
First-line per ACG 2024 in regions of high clarithromycin resistance (>15%); India falls in this category
Concomitant non-bismuth quadruple therapy[1]
PPI + amoxicillin + clarithromycin + metronidazole
- Adult
- PPI BD + amoxicillin 1 g BD + clarithromycin 500 mg BD + metronidazole 500 mg BD — 14 days
- Paediatric
- Per weight per ESPGHAN paediatric guideline
Alternative first-line; only use where clarithromycin resistance <15%
Vonoprazan-based dual therapy[1]
Potassium-competitive acid blocker + amoxicillin
- Adult
- Vonoprazan 20 mg BD + amoxicillin 1 g TID — 14 days
- Paediatric
- —
Newer first-line option per VOQUEZNA-CAB; superior acid suppression than PPI; emerging data for clarithromycin-resistant strains
Levofloxacin triple (salvage)[1]
Salvage regimen
- Adult
- PPI BD + amoxicillin 1 g BD + levofloxacin 500 mg daily — 10–14 days
- Paediatric
- —
Second-line salvage when initial therapy fails; do NOT use clarithromycin in retreatment
Rifabutin-containing rescue regimen[1]
Rescue therapy
- Adult
- PPI BD + amoxicillin 1 g BD + rifabutin 150 mg BD — 14 days
- Paediatric
- —
Refractory H. pylori after multiple eradication failures; specialist
Safety-net
Referral criteria
- Active peptic ulcer bleeding with H. pyloriHospital admission; gastroenterology for endoscopic haemostasis[1]
- Gastric MALT lymphomaGastroenterology and haematology / oncology[1]
- Multiple eradication failuresGastroenterology for culture-and-sensitivity and rescue regimen[1]
- H. pylori with gastric atrophy or intestinal metaplasiaGastroenterology for endoscopic surveillance[1]
Clinical summary
Diagnosis and eradication of H. pylori — non-bismuth quadruple or bismuth quadruple regimens reflecting rising clarithromycin resistance.