AGA Clinical Practice Update on the Management of Refractory Helicobacter pylori Infection: Expert Review

Abstract

The purpose of this CPU Expert Review is to provide clinicians with guidance on the management of Helicobacter pylori after an initial attempt at eradication therapy fails, including best practice advice on specific regimen selection, and consideration of patient and systems factors that contribute to treatment efficacy. This Expert Review is not a formal systematic review, but is based upon a review of the literature to provide practical advice. No formal rating of the strength or quality of the evidence was carried out. Accordingly, a combination of available evidence and consensus-based expert opinion were used to develop these best practice advice statements.

Keywords: Adherence; Antibiotics; CYP2C19; Clinical Management; Gastro Neoplasm; Proton Pump Inhibitor.

Figure 1.

Factors impacting failure to eradicate H. pylori infection. CagA cytotoxin-associated antigen A; IL, interleukin; VacA, vacuolating cytotoxin A.

Figure 2.

Treatment algorithm for refractory H. pylori infection. ¹Limited evidence guiding therapy in individuals with true penicillin allergy ²With high-dose or high-potency PPI, amoxicillin 750 mg TID ³High-dose metronidazole (1.5–2g divided) ⁴Only if clarithromycin sensitive strain ⁵High-dose dual PA = amoxicillin 2–3g daily in 3–4 divided doses + high-dose PPI BID. PA in place of PAR may be considered, although one study from US demonstrated superiority of PAR compared to PA as first-line treatment (Graham et al. 2020); however, this has not been directly compared in refractory H pylori treatment. P, PPI; C, Clarithromycin; A, Amoxicillin; M, Metronidazole; B, Bismuth; T, Tetracycline; R, Rifabutin; L, Levofloxacin