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 TID — 14 days | — | First-line per ICMR consensus given high local clarithromycin resistance (>15% in most Indian regions); cure rates ~85–90% |
| 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 | — | Alternative first-line where local clarithromycin resistance documented <15%; check local antibiogram |
| Levofloxacin triple (salvage)[1] | Salvage regimen | PPI BD + amoxicillin 1 g BD + levofloxacin 500 mg daily — 10–14 days | — | Second-line after first-line failure; do NOT repeat clarithromycin |
| Rifabutin-containing rescue[1] | Rescue therapy | PPI BD + amoxicillin 1 g BD + rifabutin 150 mg BD — 14 days | — | Refractory H. pylori after multiple failures |
Bismuth quadruple therapy (BQT)[1]
PPI + bismuth + tetracycline + metronidazole
- Adult
- PPI BD + bismuth subcitrate 120 mg QID + tetracycline 500 mg QID + metronidazole 500 mg TID — 14 days
- Paediatric
- —
First-line per ICMR consensus given high local clarithromycin resistance (>15% in most Indian regions); cure rates ~85–90%
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
- —
Alternative first-line where local clarithromycin resistance documented <15%; check local antibiogram
Levofloxacin triple (salvage)[1]
Salvage regimen
- Adult
- PPI BD + amoxicillin 1 g BD + levofloxacin 500 mg daily — 10–14 days
- Paediatric
- —
Second-line after first-line failure; do NOT repeat clarithromycin
Rifabutin-containing rescue[1]
Rescue therapy
- Adult
- PPI BD + amoxicillin 1 g BD + rifabutin 150 mg BD — 14 days
- Paediatric
- —
Refractory H. pylori after multiple failures
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
ICMR-aligned diagnosis and eradication of H. pylori infection in adults — bismuth quadruple therapy first-line given high local clarithromycin resistance.