Helicobacter pylori triple therapy - based on whether penicillin allergic or not

Treatment regimes in adults if H pylori positive

If no penicllin allergy:

• FIRST-LINE:
  • 7 days, PPI twice daily
    • PLUS amoxicillin 1g BD
    • PLUS either clarithromycin 500mg BD OR metronidazole 400mg BD
      
      
• ONGOING SYMPTOMS after first-line
  • SECOND-LINE:
    • 7 days, PPI twice daily
      • PLUS amoxicillin 1g BD
      • PLUS second antibiotic not used in first line, either clarithromycin 500mg BD OR metronidazole 400mg BD
        
        
• ONGOING SYMPTOMS after first-line AND previous exposure to Metronidazole and clarithromycin
  • SECOND-LINE, 7 days, PPI twice daily
    • PLUS amoxicillin 1g BD
    • PLUS second antibiotic, either tetracycline hydrochloride 500mg QDS OR levofloxacin 250mg BD

if penicillin allergy:

• FIRST-LINE: 7 days, PPI twice daily PLUS clarithromycin 500mg BD PLUS metronidazole 400mg BD
  
  
• First-line with previous CLAR exposure OR Second-line with previous levofloxacin exposure
  • 7 days, PPI twice daily
    • PLUS (bismuth subsalicylate 525mg QDS OR tripotassium dicitratobismuthate 240mg QDS)
    • PLUS tetracycline hydrochloride 500mg QDS
    • PLUS metronidazole 400mg BD
      
      
• ONGOING SYMPTOMS after first-line and NO previous exposure to levofloxacin
  • SECOND-LINE: 7 days, PPI twice daily
    • PLUS metronidazole 400mg BD
    • PLUS levofloxacin 250mg BD

PPI medication:

• lansoprazole 30mg BD, omeprazole 20-40mg BD, pantoprazole 40mg BD, esomeprazole 20mg BD, rabeprazole 20mg BD
  
  
• if post gastro-duodenal bleed, start HP treatment only when patient can take oral medication
  
  
• If diarrhoea develops, consider Clostridium difficile and review need for treatment
  
  
• only offer longer duration or third-line eradication on advice from a specialist.
  • Third line: 10 days of PPI twice daily, PLUS bismuth subsalicylate 525mg QDS, PLUS 2 antibiotics as above not previously used, OR rifabutin 150mg BD, OR furazolidone 200mg BD

Reference:

• PHE (February 2019). Test and treat for Helicobacter pylori (HP) in dyspepsia.