H. pylori Persisting After Bismuth Quadruple Therapy: Next-Line Management in Peptic Ulcer Disease
This protocol covers patients with peptic ulcer disease in whom Helicobacter pylori infection has persisted despite a completed prior eradication attempt — a scenario collectively referred to as salvage therapy. The patient has no penicillin allergy.
Clinical Scenario
Persistent H. pylori infection despite previous eradication therapy (treatment-experienced); no penicillin allergy. The umbrella term "salvage therapy" refers to any treatment provided to patients with persistent H. pylori infection despite initial therapy. Of available salvage regimens, only optimized bismuth quadruple therapy is suitable for patients with a true penicillin allergy — this protocol applies to those without that restriction.
Previous Treatment — Why This Protocol Is Needed
The prior line was optimized bismuth quadruple therapy (BQT). Its goal — confirmed eradication of H. pylori, verified by a negative urea breath test, fecal antigen test, or biopsy-based test performed at least 4 weeks after completing therapy — was not achieved. Failure to meet that endpoint is the trigger for escalation to this next-line protocol.
Next-Step Approach (Partial Overview)
For patients who have already received optimized BQT and still carry active infection, a rifabutin-based triple therapy is the suggested next step. Full regimen details are available in the structured protocol.
Clinical Goals
Confirmed eradication of H. pylori infection, verified by a negative urea breath test, fecal antigen test, or biopsy-based test performed no sooner than 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 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 wk after completion of therapy.
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