Clinical scenario

This protocol addresses patients with environmental metaplastic atrophic gastritis who remain H. pylori-positive after a prior eradication attempt. The patient is treatment-experienced and has no penicillin allergy.

About salvage therapy

The umbrella term "salvage therapy" refers to any treatment provided to patients with persistent H. pylori infection despite initial therapy. Choosing the next regimen requires accounting for prior treatment history and allergy status — not all salvage options apply equally to every patient.

Previous step — eradication goal not reached

The prior step was salvage eradication with optimized bismuth quadruple therapy (BQT). The required endpoint — confirmation of H. pylori eradication by a test of cure (urea breath test, fecal antigen test, or biopsy-based test) at least 4 weeks after completing therapy — was not achieved. This protocol describes what comes next.

Next-step approach (partial overview)

For treatment-experienced patients who have previously received optimized BQT and still have active H. pylori infection, a rifabutin-based triple salvage regimen is the evidence-based next step. The full protocol — including agent selection, duration, and administration guidance — is available via the link below.

Treatment goal

Eradication of H. pylori infection confirmed by a test of cure — urea breath test, fecal antigen test, or biopsy-based test — at least 4 weeks after completion of therapy.

References

DOI: 10.14309/ajg.0000000000002968

The umbrella term "salvage therapy" refers to any treatment provided to patients with persistent H. pylori infection despite initial therapy.
Of the recommended and suggested salvage regimens, only optimized BQT is suitable for patients with a true penicillin allergy.
In treatment-experienced patients with persistent H. pylori infection who have received BQT, rifabutin triple therapy is suggested (conditional recommendation; low quality of evidence).
Based on the available evidence and expert consensus, we suggest rifabutin triple therapy for 14 days in treatment-experienced patients with persistent H. pylori infection who have previously received optimized BQT.
All patients who are treated for H. pylori infection should undergo a test of cure with an appropriately conducted urea breath test, fecal antigen test, or biopsy-based test at least 4 weeks after completion of therapy.

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