Environmental Metaplastic Atrophic Gastritis — H. pylori Still Positive After Rifabutin Triple Therapy
This protocol applies to treatment-experienced patients with environmental metaplastic atrophic gastritis (DA42.1) whose H. pylori infection has persisted despite a prior rifabutin-based salvage course, and who have no penicillin allergy.
Clinical scenario
The patient has confirmed persistent H. pylori infection after at least one previous eradication attempt. They are treatment-experienced with no penicillin allergy, and have already completed a rifabutin triple therapy salvage regimen.
Why this protocol applies: prior salvage line did not reach its goal
Rifabutin triple therapy — combining a PPI with amoxicillin and rifabutin — did not achieve confirmed H. pylori eradication. Failure is defined as a positive test of cure (urea breath test, fecal antigen test, or biopsy-based test) at least 4 weeks after completing that regimen. This outcome triggers the approach below.
Next step: susceptibility-guided salvage
The next salvage step is guided by antibiotic susceptibility testing — the regimen selected depends on which sensitivities are confirmed in the persisting strain. The complete protocol specifies which approach applies in each susceptibility scenario.
Treatment goal
Confirmed eradication of H. pylori, verified by an appropriately conducted test of cure — urea breath test, fecal antigen test, or biopsy-based test — at least 4 weeks after completing 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 that is confirmed to be clarithromycin-sensitive, PPI- or PCAB-clarithromycin triple therapy is suggested.
- In treatment-experienced patients with persistent H. pylori infection, levofloxacin triple therapy is suggested in patients with known levofloxacin-sensitive H. pylori strains and when optimized bismuth quadruple or rifabutin triple therapies have previously been used or are unavailable (conditional recommendation, low quality of evidence).
- HDDT consists of potent gastric acid suppression therapy (e.g., high-dose PPI or PCAB) and high-dose amoxicillin, preferably for 14 days.
- 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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