Sandbox MKK

The ACG’s 2007 treatment guideline on the management of H. pylori infection (26) listed the following as established indications for diagnosis and treatment:

Active PUD (gastric or duodenal).

Confirmed history of PUD (not previously treated for H. pylori)

Gastric MALT lymphoma (low grade).

After endoscopic resection of EGC.

Recommenend first line treatment for Helicobacter pylori

Regimen	Drug dose	Dosing frequency	Duration(days)	FDA approval
Clarithromycin triple	PPI(standard or double dose Clarithromycin(500mg) Amoxicillin(1gm)or Metronidazole(500mg TID)	BID	14 days	YES†
Bismuth Quadruple	PPI(standard dose) Bismuth subcitrate (120-300mg)or Subsalicylate (300mg) Tetracyclin(500mg) Metronidazole(250-500mg)	BID QID QID TID to QID (500mg)	10-14 days	NO‡
Concomitant	PPI (standard dose) Clarithromycin (500mg) Amoxicillin(1gm) Nitroimidazole(500mg)	BID	10 -14 days	NO
Sequential	PPI(standard dose)+Amoxicillin(1gm) PPI,Clarithromycin(500mg)+Nitroimidazole(500mg)	BID BID	5-7 days 5-7 days	NO
Hybrid	PPI(standard)+Amoxicillin(1gm) PPI,Amoxicillin,Clarithromycin(500mg),Nitroimidazole(500mg)	BID BID	7 days 7 days	NO
Levofloxacin triple	PPI(standard dose) Levofloxacin(500mg) Amoxicillin(1gm)	BID QID BID	10-14 days	NO
Levofloxacin sequential	PPI(standard or double dose)+Amoxicillin(1 gm) PPI,Amoxicillin,Levofloxacin(500mg QD),Nitroimidazole(500mg)	BID BID	5-7 days	NO
LOAD	Levofloxacin(250mg) PPI(double dose) Nitazoxanide(500mg) Doxycycline(100mg)	QD QD BID QD	7-10 days	NO

†: Several PPI,Clarithromycin and Amoxicillin combination have achieved FDA approval ,PPI,Clarithromycin,Metronidazole is not an FDA approved treatment regimen.

‡: PPI,Bismuth,Tetracycline and metronidazole precribed separately is not an FDA approval treatment regimen .However ,Pylera,a combination product conataining Bismuth subcitrate,Tetracycline ,Metronidazole combination with PPi for 10 days is an FDA approved regimen.

Adjuvant therapy in the treatment of H. pylori infection:

Emerging evidence suggests an inhibitory effect of Lactobacillus and Bifidobacterium species on H. pylori. Furthermore, these probiotic strains may also help to reduce the side effects of eradication therapies and improve compliance with therapy.

Selection of firstline Treatment

•Is there a penicillin (PCN) allergy? •Previous macrolide (MCL) exposure for any reason ?

•PCN allergy: No •MCL exposure: No

•PCN allergy: No •MCL exposure: Yes

•PCN allergy: Yes •MCL exposure: No

•PCN allergy: Yes •MCL exposure: Yes

Recomended treatment: •Bismuth quadruple •Clarithromycin triple with amoxicillin Other options: •Sequential •HYBRID •Levofloxacin triple •Levofloxacin sequential •LOAD

Recomended treatment: •Bismuth quadruple •Levofloxacin sequential Other options: •Concomitant therapy •Sequential therapy • HYBRID •LOAD

Recomended treatment: •Bismuth quadruple •Clarithromycin triple with metronidazole •Bismuth quadruple

Recomended treatment: •Bismuth quadruple •Clarithromycin triple with metronidazole •Bismuth quadruple

Persistent Helicobacter pylori infection

Patient recieved clarithromycin triple therapy

Patient received Bismuth quadriple therapy

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