Which medications are used to treat resistant Helicobacter pylori (H pylori) infection?

Updated: Jul 21, 2021
  • Author: Luigi Santacroce, MD; Chief Editor: BS Anand, MD  more...
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The goals of pharmacotherapy are to eradicate the microorganism, to prevent complications, and to reduce morbidity. Triple therapies are used, including regimens that include amoxicillin, tetracycline, and rifabutin.

Increasing resistance to antibiotics has made alternative treatments necessary. Antibiotic resistance phenomena are now observed with a certain frequency in H pylori infections; occasionally, even after the use of different eradicating protocols, H pylori is not eradicated. [20, 21] In such cases treatment with rifabutin may be indicated.

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.

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.

On April 1, 2020, the US Food and Drug Administration (FDA) recommended the immediate withdrawal of ranitidine from the market based on findings of unacceptable levels of N-Nitrosodimethylamine (NDMA), a possible carcinogen. [22] In July, 2021, the original report was retracted at the request of the authors. [23] The FDA may consider allowing ranitidine products back on the market if they are proven stable during storage and NDMA amounts do not increase to unsafe levels over time. [24, 25]

Several studies are underway to elucidate the role of nanotechnology in the treatment of H pylori infection using nanoparticles synthesized with antibiotics or other agents. [26, 27, 28, 29]

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