Fast Five Quiz: Review Key Aspects of Peptic Ulcer Disease

Jamie Shalkow, MD


May 11, 2017

The management of patients with PUD is based on the etiology, ulcer characteristics, and anticipated natural history.

The 2017 ACG guideline for the treatment of H pylori infection indicates that selection of a management regimen should take into account any previous antibiotic exposure(s). The guideline also includes the following therapeutic strategies for first-line treatment:

  • 10-14 days of bismuth quadruple therapy (bismuth, proton pump inhibitor [PPI], tetracycline, and a nitroimidazole) (strong recommendation), particularly in those with previous macrolide exposure or who are penicillin allergic

  • (Recommended option) 10-14 days of concomitant PPI, clarithromycin, amoxicillin, and a nitroimidazole (strong recommendation)

  • 14 days of clarithromycin triple therapy (clarithromycin, a PPI, and amoxicillin or metronidazole) should be reserved for patients with no history of macrolide exposure who live in regions where clarithromycin resistance among H pylori isolates is known to be low (<15%) (conditional recommendation)

  • (Suggested option) 5-7 days of sequential therapy with a PPI and amoxicillin, followed by 5-7 days with clarithromycin, a PPI, and a nitroimidazole (conditional recommendation)

  • (Suggested option) 7 days of a hybrid therapy with a PPI and amoxicillin, followed by 7 days with a PPI, amoxicillin, clarithromycin, and a nitroimidazole (conditional recommendation)

  • (Suggested option) 10-14 days of levofloxacin triple therapy (levofloxacin, a PPI, and amoxicillin) (conditional recommendation)

  • (Suggested option) 5-7 days of fluoroquinolone sequential therapy (a PPI and amoxicillin), followed by 5-7 days of a PPI, fluoroquinolone, and nitroimidazole (conditional recommendation)

Salvage treatment regimens include the following:

  • (Recommended option) Bismuth quadruple therapy or levofloxacin triple therapy for 14 days (strong recommendations)

  • Avoid clarithromycin triple therapy (conditional recommendation)

  • (Suggested option) Concomitant therapy for 10-14 days (conditional recommendation)

  • (Suggested option) Rifabutin triple regimen (rifabutin, a PPI, and amoxicillin) for 10 days (conditional recommendation)

  • (Suggested option) High-dose dual therapy (a PPI and amoxicillin) for 14 days (conditional recommendation)

Salvage treatment regimens if first-line therapy fails and H pylori infection persists include the following options:

  • Avoid previously used antibiotics, if feasible (strong recommendation)

  • Preferred for patients who previously received first-line clarithromycin regimens: bismuth quadruple therapy or levofloxacin salvage regimens (conditional recommendation)

  • Preferred for patients who previously received first-line bismuth quadruple therapy: clarithromycin or levofloxacin-containing salvage regimens (conditional recommendation)

Dual therapies, which are alternative regimens for treating H pylori infection, are usually not recommended as first-line therapy because of a variable cure rate that is significantly less than the cure rate achieved with triple therapy. Eradication of infection should be confirmed 4 or more weeks after the completion of therapy.

For more the treatment of PUD, read here.


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