Diarrhea, PPI Use, and Pain in a Restaurant Worker From Mexico

Jaimy Villavicencio Kim, MD; John W. Birk, MD


November 18, 2022

Several first-line regimens are available for the treatment of H pylori infection, which include antibiotics and PPIs. None of these regimens have eradication rates above 90%. When selecting a regimen, careful attention must be paid to patients' prior antibiotic use and whether they live in a region where the prevalence of clarithromycin-resistant H pylori is high.[17] If the patient has been exposed to a macrolide before, clarithromycin-based therapy should be avoided. If the patient is allergic to penicillin, amoxicillin should be avoided.[17] The biggest barrier to successful treatment is medication compliance, especially with the more complex four-times-a-day multiple-drug regimens.

Some first-line options for the treatment of H pylori infection include:

  1. Quadruple therapy with bismuth, tetracycline, nitroimidazole, and a PPI for 10-14 days

  2. Triple therapy with clarithromycin, amoxicillin, and a PPI for 14 days

  3. Triple therapy with amoxicillin, a PPI, and levofloxacin for 10-14 days

  4. A PPI, clarithromycin, amoxicillin, and nitroimidazole for 10-14 days

  5. A PPI and amoxicillin for 7 days, followed by a PPI, amoxicillin, clarithromycin, and nitroimidazole for 7 days (hybrid)

  6. A PPI and amoxicillin for 5-7 days, followed by a PPI, fluoroquinolone, and nitroimidazole for 5-7 days (sequential)

  7. LOAD: levofloxacin, a PPI, nitazoxanide, and doxycycline for 7-10 days

Treatment usually lasts 10-14 days, and common adverse effects of the medications include nausea, dysgeusia, dyspepsia, abdominal pain, and diarrhea. A decision can also be made whether to use concomitant therapy or sequential therapy (eg, option 6). Hybrid therapy is a combination of sequential and concomitant therapy (eg, option 5).

Testing to confirm eradication should be done at least 4 weeks after the completion of antibiotic therapy, using the urea breath test, the stool antigen test, or a biopsy-based test. PPI therapy should be withheld 1-2 weeks before testing.[17] Treatment failure is in the 15%-30% range, and nonadherence to the antibiotic regimen and multidrug resistance are common factors.[17] Thus, the patient should be informed that retreatment is not unexpected.

On the basis of the American College of Gastroenterology (ACG) guidelines, clarithromycin triple therapy should be avoided as salvage therapy. The ACG recommends concomitant salvage therapy for 14 days.[17] Rifabutin-based triple therapy is an alternative, which is recommended for 10 days.[17] Salvage therapies include:

  • Bismuth quadruple therapy for 14 days

  • Levofloxacin, a PPI, and amoxicillin for 14 days

  • A PPI, clarithromycin, amoxicillin, and nitroimidazole for 14 days

  • Rifabutin, a PPI, and amoxicillin for 10 days

  • High-dose dual therapy: A PPI (standard to double dose) and amoxicillin (1 g three times daily or 750 mg four times daily)

The patient in this case had a stool test for H pylori antigen along with his initial tests; the result was positive. He was treated with amoxicillin, clarithromycin, and a PPI for 14 days. He reported some nausea with treatment but was able to take all antibiotics as directed. His diarrhea resolved; however, he had persistent epigastric discomfort. A stool antigen test was performed 6 weeks after he had finished therapy, and the result was positive. When the patient was asked about prior antibiotic therapy, he did recall taking azithromycin (a Z-Pak) in the past for an upper respiratory tract infection. He started a 14-day regimen of levofloxacin, a PPI, and amoxicillin, with plans to repeat testing 4 weeks after finishing salvage therapy. Eradication rates after two regimens are thought to be approximately 98%, and about 2% of patients will require third-line salvage therapy.[20]Another concern is antibiotic resistance, which can lead to treatment failure. Experts have urged that new guidelines are needed to help prevent and confront heteroresistant H pylori infection in the future.[21]


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