AGA: Best Practice Advice for Refractory H pylori

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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2 thoughts on “AGA: Best Practice Advice for Refractory H pylori

  1. 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.

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