What are the 2021 American Gastroenterological Association (AGA) recommendations for Helicobacter pylori (H pylori) infection?

Updated: Jul 21, 2021
  • Author: Luigi Santacroce, MD; Chief Editor: BS Anand, MD  more...
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The American Gastroenterological Association (AGA) advises that in the setting of any history of treatment with macrolides or fluoroquinolones, avoid clarithromycin- or levofloxacin-based regimens, respectively, because of the higher risk of resistance. [12] Consider amoxicillin, tetracycline, and rifabutin as subsequent therapies in refractory H pylori infection as resistance to these antibiotics is rare.

The AGA advises that if first-line therapy with bismuth quadruple therapy is ineffective, clinicians and patients should jointly decide on the selection of second-line options between (a) levofloxacin- or rifabutin-based triple-therapy regimens with a high-dose dual proton pump inhibitor (PPI) and amoxicillin, and (b) an alternative bismuth-containing quadruple therapy. [12]

When using metronidazole-containing regimens, consider adequate dosing of metronidazole (1.5–2 g daily in divided doses) with concomitant bismuth therapy to improve success of eradication therapy.

If there is no history of anaphylaxis, consider penicillin allergy testing in patients who have been labeled as having this allergy to delist penicillin as an allergy and potentially enable its use. Use amoxicillin at a daily dose of at least 2 g divided three or four times per day to avoid low trough levels.

Because inadequate acid suppression is associated with H pylori eradication failure, consider using high-dose and more potent PPIs, PPIs not metabolized by CYP2C19, or potassium-competitive acid blockers, if available, in patients with refractory H pylori infection.

Higher eradication success is achieved with longer treatment durations relative to those of shorter durations (eg, 14 days vs 7 days). Thus, as appropriate, choose longer treatment durations for treating refractory H pylori infection.

Sshared decision making regarding ongoing attempts to eradicate H pylori may be appropriate in some settings. Carefully evaluate the potential benefits of H pylori eradication against potential adverse effects and the inconvenience of repeated antibiotic exposure and high-dose acid suppression, particularly in vulnerable populations (eg elderly).

In the setting of two failed therapies with confirmed patient adherence, consider H pylori susceptibility testing to guide the selection of subsequent regimens.

It is essential to collect local data on H pylori eradication success rates for each regimen, as well as patient demographic and clinical factors (including prior non-H pylori antibiotic exposure). Make aggregated data publicly available to guide local selection of H pylori eradication therapy.

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