Helicobacter pylori

Diagnosis of H. pylori infection

  • All patients with symptoms related to the upper gastrointestinal tract should be tested for H. pylori.
  • Non-invasive testing is recommended in situations where there is a low risk of the patient having gastric cancer, such as those up to 45 years and without alarm symptoms (such as weight loss, dysphagia, overt gastrointestinal bleeding, abdominal mass or iron-deficient anaemia).
  • Non-invasive tests include:
    • Urea breath test (UBT): recommended non-invasive test of choice, where available
    • Faecal antigen testing: less sensitive than UBT but with high specificity. Can be performed if UBT not available.
    • H. pylori serology: less sensitive and specific. Perform only if UBT or faecal antigen testing is unavailable.
  • For patients over 45 years or with alarm symptoms, endoscopy is recommended.
  • PPIs should be avoided two weeks before any testing is performed as they may increase the risk of a false negative result.
  • Antimicrobials should also be avoided for four weeks before testing.

Treatment

Treatment table is intended to be viewed in desktop format

Drug Dose  Duration Notes
1st choice options:
Clarithromycin-based triple therapy

PPI

PLUS

Clarithromycin

PLUS

Amoxicillin

Every 12 hours

 

500mg every 12 hours

 

1g every 12 hours

14 days

 

 

 

 

 
OR

Bismuth quadruple therapy (if available):

Consider bismuth regimen first line if:

  • Allergy to first line antibiotic(s)
  • Patient has received clarithromycin in the past year

PPI

PLUS

Bismuth subcitrate

PLUS

Metronidazole

PLUS

Doxycycline

Every 12 hours

 

120 mg every 6 hours

 

400 mg every 8 hours

 

100mg every 12 hours

14 days

 

 

 

 

 

 

Please check with Community Pharmacist
for further information re availability of bismuth
products and reimbursement status.

 

 

 

 

 

2nd choice options:

Second-line therapy depends on the first-line therapy and should not be the same treatment. The options are:

  • Clarithromycin-based triple therapy for 14 days
  • Bismuth quadruple therapy for 14 days
  • Levofloxacin-based triple therapy for 14 days
 Clarithromycin-based triple therapy (for penicillin allergy)
 

PPI

PLUS

Clarithromycin

PLUS

Metronidazole

 

 

Every 12 hours

 

500mg every 12 hours

 

400mg every 12 hours

 

 14 days

 

 

 

 

 
 OR   

Levofloxacin-based triple therapy:

  • Should be reserved for second line, in the case of failed eradication
 

PPI

PLUS

Levofloxacin

PLUS

Amoxicillin

 

 

Every 12 hours

 

250mg every 12 hours

 

1g every 12 hours

 

 14 days

 

 

 

 

 

Post eradication testing

  • Must be performed at least eight weeks following completion of therapy.
  • If gastroscopy is not required, a urea breath test is recommended.
  • The stool antigen test may be used as an alternative, but is less accurate.
  • Serology testing is not recommended for eradication confirmation as antibodies may persist for months following eradication.

Failure of first line regimen

  • In cases where first line regimen has failed to eradicate infection, a different treatment regimen should be used as second line.
  • Post-eradication testing is recommended (as above).
  • If the patient cannot take a second line regimen due to e.g. allergy consider referral to gastroenterology service for endoscopy with culture and antimicrobial susceptibility testing to tailor therapy.

Failure of second line regimen

  • Refer to gastroenterology service for endoscopy with culture and antimicrobial susceptibility testing to tailor therapy and increase the likelihood of eradication success.

Patient Information

Visit HPSC Information Leaflets pages for the General Public, (MRSA, CRE, etc)

Safe Prescribing (visit the safe prescribing page)

Reviewed December 2020 - minor update November 2023


antibiotics banner