SC Shah et al. Gastroenterol 2021; 160: 1831-1841. Full text: AGA Clinical Practice Update on the Management of Refractory Helicobacter pylori Infection: Expert Review
Key recommendations:
- Best Practice Advice 4: If bismuth quadruple therapy failed as a first-line treatment, shared decision making between providers and patients should guide selection between (a) levofloxacin- or rifabutin-based triple-therapy regimens with high-dose dual proton pump inhibitor (PPI) and amoxicillin, and (b) an alternative bismuth-containing quadruple therapy, as second-line options
- Best Practice Advice 5: When using metronidazole-containing regimens, providers should consider adequate dosing of metronidazole (1.5–2 g daily in divided doses) with concomitant bismuth therapy, because this may improve eradication success rates irrespective of observed in vitro metronidazole resistance.
- Best Practice Advice 6: In the absence of a history of anaphylaxis, penicillin allergy testing should be considered in a patient labeled as having this allergy in order to delist penicillin as an allergy and potentially enable its use. Amoxicillin should be used at a daily dose of at least 2 g divided 3 times per day or 4 times per day to avoid low trough levels.
- Best Practice Advice 8:Longer treatment durations provide higher eradication success rates compared with shorter durations (eg, 14 days vs 7 days). Whenever appropriate, longer treatment durations should be selected for treating refractory H pylori infection.
- Best Practice Advice 10: After 2 failed therapies with confirmed patient adherence, H pylori susceptibility testing should be considered to guide the selection of subsequent regimens.
- Table 1 in report details specific regimens
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- Twyman’s Law | gutsandgrowth
gutsandgrowth 
These guidelines seem inconsistent with NASPGHAN guidelines from 2016 in some aspects? Does pediatric H. pylori need to stick with pediatric guidelines?
In my opinion, the pediatric guidelines need to be updated. My suspicion is that the resistance patterns with H pylori are likely to be similar in adults and children. If this is accurate, then 4-drug regimens are needed in children, as in adults, to increase eradication rates.