Table 3:
Guidelines for prescribing successful H. pylori therapies
| Take an antibiotic use history and if available review prior prescriptions to identify the antibiotics where resistance is likely. |
| Prescribe only therapies that are proven to be effective locally (i.e., cure rates ≥90%) or preferably highly effective locally (i.e., cure rates of ≥95%). |
| The rules of thumb regarding therapy include: only use antibiotics to which the organism is susceptible. Antibiotic doses and dosing frequency are based on local results. A duration of 14-days is best. Esomeprazole or rabeprazole 40 mg b.i.d. are preferred as they are more potent and minimally affected by CYP2C19 metabolism. |
| Do not prescribe clarithromycin, metronidazole, or levofloxacin for H. pylori infections unless susceptibility has been confirmed. The exceptions are use of metronidazole in bismuth quadruple therapy, and confirmed excellent outcomes locally with these triple therapies. |
| Quinolones (e.g., levofloxacin) have recently been associated with severe long term side effects and should not be prescribed unless a) susceptibility is confirmed and b) no other options are available. |
| Resistance to tetracycline, amoxicillin and rifabutin are still rare |
| Therapies that contain unneeded antibiotics (e.g., concomitant, sequential, hybrid, reverse hybrid and vonoprazan clarithromycin triple therapies). should not be prescribed as the unneeded antibiotic (most often clarithromycin) unnecessarily contributes to increased global antimicrobial resistance |
| Perform Test-of-Cure after every treatment to provide continuing feedback regarding current effectiveness. |
| Share Test-of-Cure results with partners and colleagues so as to contribute to the local and regional experience regarding which H. pylori therapies are locally effective vs. ineffective. |
| Successful use of an empiric therapy is critically dependent on monitoring its effectiveness and the willingness to abandon an empiric therapy if its effectiveness declines. |
| Susceptibility data must be coupled with optimized therapy to achieve its full potential |