Peptic Ulcer Disease: When H. pylori Persists After Rifabutin Triple Therapy
Clinical scenario
This protocol applies to patients with peptic ulcer disease who remain Helicobacter pylori-positive despite previous eradication attempts — treatment-experienced patients without a penicillin allergy. "Salvage therapy" refers to any treatment given to patients with persistent H. pylori infection after an initial eradication course has not succeeded.
Previous treatment — failure condition
The prior therapy at this stage was rifabutin triple therapy for 14 days, used after optimised bismuth quadruple therapy had already been tried. Escalation to this protocol occurs when that regimen did not achieve confirmed eradication — defined as a negative urea breath test, fecal antigen test, or biopsy-based test obtained no earlier than 4 weeks after completing therapy.
Next-step approach (partial overview)
After rifabutin triple therapy has not achieved eradication, the approach shifts to antibiotic susceptibility-guided salvage therapy — the specific regimen chosen depends on the documented sensitivity profile of the strain. Which regimen applies to which susceptibility result, and the full clinical algorithm, are available in the structured protocol.
Treatment goal
Eradication of H. pylori infection, confirmed by a negative urea breath test, fecal antigen test, or biopsy-based test performed 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 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).
- Although we do not recommend HDDT as a routine salvage regimen in patients with persistent H. pylori infection, it may be considered in selected scenarios such as patients in whom optimized BQT or rifabutin triple therapy is not an option; antibiotic susceptibility testing is unavailable or does not yield usable results; or in patients with a strain of H. pylori that is sensitive only to amoxicillin.
- 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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