Figure 2.

Treatment algorithm for refractory H. pylori infection.

¹Limited evidence guiding therapy in individuals with true penicillin allergy

²With high-dose or high-potency PPI, amoxicillin 750 mg TID

³High-dose metronidazole (1.5–2g divided)

⁴Only if clarithromycin sensitive strain

⁵High-dose dual PA = amoxicillin 2–3g daily in 3–4 divided doses + high-dose PPI BID. PA in place of PAR may be considered, although one study from US demonstrated superiority of PAR compared to PA as first-line treatment (Graham et al. 2020); however, this has not been directly compared in refractory H pylori treatment.

P, PPI; C, Clarithromycin; A, Amoxicillin; M, Metronidazole; B, Bismuth; T, Tetracycline; R, Rifabutin; L, Levofloxacin