Quadruple Therapy for Helicobacter Pylori Favored in Toronto Guidelines

Toronto consensus guidelines (C Fallone et al. Gastroenterol 2016l 151: 51-69) for H pylori treatment in adults emphasize use of 14 day therapy and use of quadruple regimens.  Specific recommendations included the following:

  • PAMC: PPI/amoxicillin/metronidazole/clarithromycin OR
  • PBMT: PPI/bismuth/metronidazole/tetracycline

Full text link: Toronto Consensus for the Treatment of H Pylori


Background & Aims

Helicobacter pylori infection is increasingly difficult to treat. The purpose of these consensus statements is to provide a review of the literature and specific, updated recommendations for eradication therapy in adults.


A systematic literature search identified studies on H pylori treatment. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an online platform, finalized, and voted on by an international working group of specialists chosen by the Canadian Association of Gastroenterology.


Because of increasing failure of therapy, the consensus group strongly recommends that all H pylorieradication regimens now be given for 14 days. Recommended first-line strategies include concomitant nonbismuth quadruple therapy (proton pump inhibitor [PPI] + amoxicillin + metronidazole + clarithromycin [PAMC]) and traditional bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline [PBMT]). PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole) is restricted to areas with known low clarithromycin resistance or high eradication success with these regimens. Recommended rescue therapies include PBMT and levofloxacin-containing therapy (PPI + amoxicillin + levofloxacin). Rifabutin regimens should be restricted to patients who have failed to respond to at least 3 prior options.


Optimal treatment of H pylori infection requires careful attention to local antibiotic resistance and eradication patterns. The quadruple therapies PAMC or PBMT should play a more prominent role in eradication of H pylori infection, and all treatments should be given for 14 days.

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3 thoughts on “Quadruple Therapy for Helicobacter Pylori Favored in Toronto Guidelines

  1. Pingback: ACG Guideline for Helicobacter Pylori | gutsandgrowth

  2. Pingback: Rifabutin-based Triple Therapy for H pylori | gutsandgrowth

  3. Pingback: AGA: Best Practice Advice for Refractory H pylori | gutsandgrowth

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