Helicobacter pylori infection

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

Test of cure mandatory^[1]
All treated patients tested 4–8 weeks after completing therapy with UBT or stool antigen
PPI maintenance after ulcer healing^[1]
Continue PPI for 4–8 weeks after eradication if peptic ulcer present; longer if NSAIDs continue

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

Take all four medications together for the full 10–14 days even when symptoms improve early; incomplete therapy drives resistance^[1]
Bismuth turns stools black — this is normal; metallic taste is common with metronidazole^[1]
Avoid alcohol with metronidazole or tinidazole (disulfiram-like reaction)^[1]

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.

References

1.ICMR Consensus on H. pylori Infection Management; Indian Society of Gastroenterology guidance (2021)