Treatment of Helicobacter pylori Infection
Publication Date: February 1, 2017
Last Updated: March 14, 2022
Recommendation statements
H. pylori infection is chronic and is usually acquired in childhood. The exact means of acquisition is not always clear. The incidence and prevalence of H. pylori infection are generally higher among people born outside North America than among people born here. Within North America, the prevalence of the infection is higher in certain racial and ethnic groups, the socially disadvantaged, and people who have immigrated to North America. (, Low)
(Factual statement)
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Since all patients with a positive test of active infection with H. pylori should be offered treatment, the critical issue is which patients should be tested for the infection. (Strong “We recommend”, )
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All patients with active peptic ulcer disease (PUD), a past history of PUD (unless previous cure of H. pylori infection has been documented), low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma, or a history of endoscopic resection of early gastric cancer (EGC) should be tested for H. pylori infection. Those who test positive should be offered treatment for the infection.
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active or history of PUD
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MALT lymphoma
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history of endoscopic resection of EGC.
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In patients with uninvestigated dyspepsia who are under the age of 60 years and without alarm features, non-endoscopic testing for H. pylori infection is a consideration. Those who test positive should be offered eradication therapy.
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efficacy
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age threshold
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When upper endoscopy is undertaken in patients with dyspepsia, gastric biopsies should be taken to evaluate for H. pylori infection. Infected patients should be offered eradication therapy. (Strong “We recommend”, High)
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Patients with typical symptoms of gastroesophageal reflux disease (GERD) who do not have a history of PUD need not be tested for H. pylori infection. However, for those who are tested and found to be infected, treatment should be offered, acknowledging that effects on GERD symptoms are unpredictable. (Strong “We recommend”, High)
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In patients taking long-term, low-dose aspirin, testing for H. pylori infection could be considered to reduce the risk of ulcer bleeding. Those who test positive should be offered eradication therapy to reduce the risk of ulcer bleeding. (Conditional (weak) “We suggest”, Moderate)
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Patients initiating chronic treatment with a non-steroidal anti-inflammatory drug (NSAID) should be tested for H. pylori infection. Those who test positive should be offered eradication therapy. (Strong “We recommend”, Moderate)
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The benefit of testing and treating H. pylori in a patient already taking an NSAID remains unclear. (Conditional (weak) “We suggest”, Low)
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Patients with unexplained iron deficiency anemia despite an appropriate evaluation should be tested for H. pylori infection. Those who test positive should be offered eradication therapy. (Conditional (weak) “We suggest”, Low)
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Adults with idiopathic thrombocytopenic purpura (ITP) should be tested for H. pylori infection. Those who test positive should be offered eradication therapy. (Conditional (weak) “We suggest”, Very low)
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There is insufficient evidence to support routine testing for and treatment of H. pylori in asymptomatic individuals with a family history of gastric cancer or patients with lymphocytic gastritis, hyperplastic gastric polyps, and hyperemesis gravidarum. (, Very low)
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Patients should be asked about any previous antibiotic exposure(s), and this information should be taken into consideration when choosing an H. pylori treatment regimen. (Conditional (weak) “We suggest”, Moderate)
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Clarithromycin triple therapy consisting of a PPI, clarithromycin, and amoxicillin or metronidazole for 14 days remains a recommended treatment in regions where H. pylori clarithromycin resistance is known to be <15% and in patients with no previous history of macrolide exposure for any reason.
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Bismuth quadruple therapy consisting of a PPI, bismuth, tetracycline, and a nitroimidazole for 10–14 days is a recommended first-line treatment option. Bismuth quadruple therapy is particularly attractive in patients with any previous macrolide exposure or who are allergic to penicillin. (Strong “We recommend”, Low)
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Concomitant therapy consisting of a PPI, clarithromycin, amoxicillin and a nitroimidazole for 10–14 days is a recommended first-line treatment option.
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Sequential therapy consisting of a PPI and amoxicillin for 5–7 days followed by a PPI, clarithromycin, and a nitroimidazole for 5–7 days is a suggested firstline treatment option.
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Hybrid therapy consisting of a PPI and amoxicillin for 7 days followed by a PPI, amoxicillin, clarithromycin and a nitroimidazole for 7 days is a suggested first-line treatment option.
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Levofloxacin triple therapy consisting of a PPI, levofloxacin, and amoxicillin for 10–14 days is a suggested first-line treatment option.
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Fluoroquinolone sequential therapy consisting of a PPI and amoxicillin for 5–7 days followed by a PPI, fluoroquinolone, and nitroimidazole for 5–7 days is a suggested first-line treatment option.
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The main determinants of successful H. pylori eradication are the choice of regimen, the patient’s adherence to a multi-drug regimen with frequent side-effects, and the sensitivity of the H. pylori strain to the combination of antibiotics administered. (, Moderate)
(Factual statement)
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Data regarding antibiotic resistance among H. pylori strains from North America remains scarce. Organized efforts are needed to document local, regional, and national patterns of resistance in order to guide the appropriate selection of H. pylori therapy. (Strong “We recommend”, Low)
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Although H. pylori antimicrobial resistance can be determined by culture and/or molecular testing, (Strong “We recommend”, Moderate)
these tests are currently not widely available in the United States.
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Whenever H. pylori infection is identified and treated, testing to prove eradication should be performed using a urea breath test, fecal antigen test or biopsybased testing at least 4 weeks after the completion of antibiotic therapy and after PPI therapy has been withheld for 1–2 weeks. (Strong “We recommend”, Low)
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for the choice of methods to test for eradication
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In patients with persistent H. pylori infection, every effort should be made to avoid antibiotics that have been previously taken by the patient. (Strong “We recommend”, Moderate)
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Bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options if a patient received a first-line treatment containing clarithromycin. Selection of best salvage regimen should be directed by local antimicrobial resistance data and the patient’s previous exposure to antibiotics. (Conditional (weak) “We suggest”, )
(for quality of evidence see individual statements below)
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Clarithromycin or levofloxacin-containing salvage regimens are the preferred treatment options, if a patient received first-line bismuth quadruple therapy. Selection of best salvage regimen should be directed by local antimicrobial resistance data and the patient’s previous exposure to antibiotics. (Conditional (weak) “We suggest”, )
(for quality of evidence see individual statements below)
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The following regimens can be considered for use as salvage treatment:
Bismuth quadruple therapy for 14 days is a recommended salvage regimen.
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Levofloxacin triple regimen for 14 days is a recommended salvage regimen.
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Concomitant therapy for 10–14 days is a suggested salvage regimen. (Conditional (weak) “We suggest”, Very low)
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Clarithromycin triple therapy should be avoided as a salvage regimen. (Conditional (weak) “We suggest”, Low)
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Rifabutin triple regimen consisting of a PPI, amoxicillin, and rifabutin for 10 days is a suggested salvage regimen.
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High-dose dual therapy consisting of a PPI and amoxicillin for 14 days is a suggested salvage regimen.
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Most patients with a history of penicillin allergy do not have true penicillin hypersensitivity. After failure of first-line therapy, such patients should be considered for referral for allergy testing since the vast majority can ultimately be safely given amoxicillin-containing salvage regimens. (Strong “We recommend”, Low)
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Recommendation Grading
Overview
Title
Treatment of Helicobacter pylori Infection
Authoring Organization
American College of Gastroenterology
Publication Month/Year
February 1, 2017
Last Updated Month/Year
January 17, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
This guideline is intended to provide clinicians working in North America with updated recommendations on the treatment of H. pylori infection.
Target Patient Population
Patients with H. Pylori infection
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Long term care, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D019072 - Antibiotic Prophylaxis, D016998 - Helicobacter, D041981 - Gastrointestinal Tract, D016480 - Helicobacter pylori
Keywords
infection, dyspepsia, Helicobacter pylori, gastrointestinal, H.pylori
Source Citation
Chey, William D MD, FACG; Leontiadis, Grigorios I MD, PhD; Howden, Colin W MD, FACG; Moss, Steven F MD, FACG. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection, American Journal of Gastroenterology: February 2017 - Volume 112 - Issue 2 - p 212-239 doi: 10.1038/ajg.2016.563
Supplemental Methodology Resources
Data Supplement, Data Supplement, Data Supplement, Data Supplement, Data Supplement
Methodology
Number of Source Documents
217
Literature Search Start Date
December 1, 2000
Literature Search End Date
September 11, 2011