Salvage therapies for H. pylori infection

Salvage therapies for H. pylori infection

Regimen	Drugs (doses)*	Dosing frequency	Duration (days)
Bismuth quadruple	PPI (standard dose^¶)	Twice daily	14
	Bismuth subcitrate (120 to 300 mg [not available in US] or 420 mg [available in North America and elsewhere as part of Pylera combination pill])^[1] or Bismuth subsalicylate (300 or 524 mg)^[1]	Four times daily
	Tetracycline (500 mg)	Four times daily
	Metronidazole (500 mg)	Three to four times daily
Levofloxacin triple	PPI (high dose or high potency^¶)	Twice daily	14
	Levofloxacin (500 mg)	Once daily
	Amoxicillin (750 mg)	Three times daily
Clarithromycin quadruple^[2]	PPI (standard dose^¶)	Twice daily	14
	Clarithromycin (500 mg)	Twice daily
	Bismuth subsalicylate (300 or 524 mg)^[1]	Four times daily
	Tetracycline (500 mg)	Four times daily
Rifabutin triple^◊	PPI (high dose or high potency^¶)	Twice daily	14
	Rifabutin (300 mg)	Once daily
	Amoxicillin (750 mg)	Three times daily
Rifabutin triple^◊ (commercially available combination capsules)	Four (4) omeprazole-amoxicillin-rifabutin combination capsules (each capsule contains 10/250/12.5 mg)	Three times daily	14
High-dose dual	PPI (high dose^¶)	Twice daily	14
High-dose dual	Amoxicillin (1 gram three times daily or 750 mg four times daily)	Three to four times daily	14

FDA: United States Food and Drug Administration; PPI: proton pump inhibitor.
* Doses are for adults with normal kidney function. Dose adjustment is warranted in patients with kidney function impairment for certain antibiotics (eg, levofloxacin, rifabutin, clarithromycin if end-stage disease).
¶ Standard dose of orally administered proton pump inhibitors include: Lansoprazole 30 mg daily, omeprazole 20 mg daily, pantoprazole 40 mg daily, rabeprazole 20 mg daily, esomeprazole 20 mg daily, or dexlansoprazole 30 mg daily.
High-dose proton pump inhibitors are double the standard dose. High-potency proton pump inhibitors include esomeprazole or rabeprazole.
◊ Rifabutin-containing regimens should be reserved for patients with ≥3 previous eradication failures. Rifabutin is an inducer of cytochrome P450 drug metabolism (ie, accelerates drug metabolism); assess potential drug interactions before use.

Reference:

Fallone CA, Chiba N, van Zanten SV, et al. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastro 2016; 151:51.
Shah SC, Iyer PG, Moss, SF. AGA Clinical Practice Update on the Management of Refractory Helicobacter pylori Infection: Expert Review. Gastroenterology 2021; 160:1831.

Adapted by permission from Macmillan Publishers Ltd: American Journal of Gastroenterology. Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol 2017; 112:212. Copyright © 2017. www.nature.com/ajg.

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Salvage therapies for H. pylori infection