Fast Five Quiz: Management of Helicobacter pylori

Steven F. Moss, MD


January 25, 2022

Because resistance to the rifamycin antibiotic rifabutin is rare, it is reasonable to consider rifabutin in a triple regimen without prior sensitivity testing. The addition of rifabutin to a high-dose amoxicillin and PPI dual regimen has been shown to significantly improve eradication rates.

Dose adjustments and the addition of bismuth may potentially overcome nitroimidazole resistance. Specifically, higher doses of metronidazole (ie, in the 1.5-2 g/d range) have been associated with significantly improved eradication rates. While these higher doses might be poorly tolerated due to gastrointestinal and other adverse effects, consumption of metronidazole in divided doses (three to four times daily) with food and the avoidance of alcohol may help to minimize these effects.

Because of increasing rates of resistance, the fluoroquinolone levofloxacin should not be considered for treatment unless the H pylori strain is known to be sensitive to it or the population levofloxacin resistance rates are known to be less than 15%. In such cases, it can be used as part of a triple-therapy regimen with a high-dose dual PPI and amoxicillin for refractory H pylori infection.

Learn more about treatment considerations in the management of H pylori infection.


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