H pylori eradication therapy (NICE)
Last edited 06/2021 and last reviewed 09/2022
Helicobacter pylori: triple therapy (1,2):
Eradication
First-line treatment in adults
- offer people who test positive for H pylori a 7-day, twice-daily
course of treatment with:
- a PPI (see table in notes) and
- amoxicillin 1g and
- either clarithromycin 500mg or metronidazole 400mg
- offer people who are allergic to penicillin a 7-day, twice-daily
course of treatment with:
- a PPI (see table in notes) and
- clarithromycin 250mg and
- metronidazole 400mg
- offer people who are allergic to penicillin and who have had previous exposure
to clarithromycin a 7-day, twice-daily course of treatment with:
- a PPI (see table in notes) and
- bismuth and
- metronidazole 400mg and
- tetracycline 500mg
Second-line treatment in adults
- offer people who still have symptoms after first-line eradication treatment
a 7-day, twice-daily course of treatment with:
- a PPI (see table in notes) and
- amoxicillin 1g bd and
- either clarithromycin 500mg bd or metronidazole 400mg bd (whichever
was not used first-line)
- offer people who have had previous exposure to clarithromycin and metronidazole
a 7-day, twice-daily course of treatment with:
- a PPI (see table) and
- amoxicillin 1g and
- a quinolone or tetracycline 500mg
- offer people who are allergic to penicillin (and who have not had previous
exposure to a quinolone) a 7-day, twice-daily course of treatment with:
- a PPI (see table) and
- metronidazole 400mg and
- levofloxacin 250mg
- offer people who are allergic to penicillin and who have had previous exposure
to a quinolone:
- a PPI (see table) and
- bismuth and
- metronidazole 400mg and
- tetracycline 500mg
Seek advice from a gastroenterologist if eradication of H pylori is not successful with second-line treatment
Notes (2):
- there is evidence that the addition of bovine lactoferrin to triple therapy
led to an increase in Helicobacter pylori eradication (3)
- a more recent meta-analysis concluded that "...supplementation with probiotics could be effective in increasing eradication rates of anti-H. pylori therapy, and could be considered helpful for patients with eradication failure. Furthermore, probiotics show a positive impact on H. pylori therapy-related side effects.." (4)
- quadruple therapy for H. pylori
- a meta-analysis revealed that quadruple therapy appeared to be more
effective than triple therapies for eradicating single-drug resistant
H. pylori infection (5)
- the study authors observed that resistance to metronidazole or clarithromycin could be overcome to a great extent with quadruple therapies given for 5 or more days, especially those containing metronidazole and clarithromycin concomitantly
- a meta-analysis revealed that quadruple therapy appeared to be more
effective than triple therapies for eradicating single-drug resistant
H. pylori infection (5)
-
PPI doses for H pylori eradication therapy (1)
PPI Dose (twice daily) Esomeprazole 20mg Lansoprazole 30mg Omeprazole 20-40mg Pantoprazole 40mg Rabeprazole 20mg
- use of quinaolones - See
MHRA advice for restrictions and precautions for using fluoroquinolone
antibiotics due to very rare reports of disabling and potentially long-lasting
or irreversible side effects affecting musculoskeletal and nervous systems.
Warnings include: stopping treatment at first signs of a serious adverse reaction
(such as tendonitis), prescribing with special caution in people over 60 years
and avoiding coadministration with a corticosteroid (March 2019)
- key points (6):
- always test for H.pylori before giving antibiotics. Treat all positives, if known DU (duodenal ulcer), GU (gastric ulcer), or low-grade MALToma. NNT in non-ulcer dyspepsia: 14.4
- do not offer eradication for GORD
- do not use clarithromycin, metronidazole or quinolone if used in the past year for any infection
- penicillin allergy:
- use PPI PLUS clarithromycin PLUS metronidazole
- if previous clarithromycin, use PPI PLUS bismuth salt PLUS metronidazole PLUS tetracycline hydrochloride
- relapse and no penicillin allergy use PPI PLUS amoxicillin PLUS clarithromycin or metronidazole (whichever was not used first line)
- relapse and previous metronidazole and clarithromycin: use PPI PLUS amoxicillin PLUS either tetracycline OR levofloxacin (if tetracycline not tolerated)
- relapse and penicillin allergy (no exposure to quinolone): use PPI PLUS metronidazole PLUS levofloxacin
- relapse and penicillin allergy (with exposure to quinolone): use PPI PLUS bismuth salt PLUS metronidazole PLUS tetracycline
- retest for H. pylori:
- post DU/GU, or relapse after second-line therapy, using Urea Breath Test or stool antigen tests, consider referral for endoscopy and culture
Reference:
- (1) NICE (October 2019).Dyspepsia and gastro-oesophageal reflux disease - Investigation and management of dyspepsia, symptoms suggestive of gastro-oesophageal reflux disease, or both
- (2) Alahdab YO, Kalayci C.Helicobacter pylori: management in 2013. World J Gastroenterol. 2014 May 14;20(18):5302-7.
- (3) Di Mario F et al. Bovine lactoferrin for Helicobacter pylori eradication: an open, randomized, multicentre study. Aliment Pharmacol Ther 2006;23:1235-40.
- (4) Tong JL et al. Meta-analysis: the effect of supplementation with probiotics on eradication rates and adverse events during Helicobacter pylori eradication therapy. Aliment Pharmacol Ther. 2007 Jan 15;25(2):155-68.
- (5) Fischbach L, Evans EL. Meta-analysis: the effect of antibiotic resistance status on the efficacy of triple and quadruple first-line therapies for Helicobacter pylori.Aliment Pharmacol Ther. 2007 Aug 1;26(3):343-57
- (6) Public Health England (June 2021). Managing common infections: guidance for primary care
management/follow-up after H. pylori eradication therapy
NICE guidance - management of dyspepsia in adults in primary care (summary section)
when is testing for H. pylori indicated?
Helicobacter pylori testing and diagnosis
retesting for H pylori (Helicobacter pylori)
Helicobacter pylori triple therapy - based on whether penicillin allergic or not