Helicobacter pylori Infection in adults

Publication: 01/01/2008  --
Last review: 26/10/2021  
Next review: 09/08/2024  
Clinical Guideline
CURRENT 
ID: 1210 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

GUIDELINE FOR TREATMENT OF HELICOBACTER PYLORI INFECTION IN ADULTS

DIAGNOSTICS

Who should be tested for H. pylori
  • Patients with uncomplicated dyspepsia that is unresponsive to lifestyle change and antacids, following a single one month course of proton pump inhibitor (PPI), without alarm symptoms (see below). In patients aged 55 years and older with unexplained and persistent recent-onset dyspepsia alone, an urgent referral for endoscopy should be made
  • Patients with peptic ulcer disease
  • Patients with gastric cancer (particularly if undergoing curative endoscopic therapy or partial gastrectomy)
  • Patients with functional dyspepsia (dyspepsia in the presence of a structurally normal upper endoscopy)
  • Patients with a first degree relative with gastric cancer
  • Patients with MALToma

Investigations required  (one of the following)

  • Stool sample (faecal antigen test)
  • CLO test (Campylobacter-like organism or rapid urease test - requires biopsy during endoscopy)

Non-antimicrobial management

  • The following washout periods are recommended before testing for H. pylori
    • PPIs – 2 weeks
    • Bismuth and antibiotics - 4 weeks
    • H2-receptor Antagonists – 48 hours
  • Follow NICE guidance for other non-antimicrobial treatment of uninvestigated dyspepsia, peptic ulcer disease, and functional dyspepsia.
     https://www.nice.org.uk/guidance/cg184

Patients who should be re-tested

Stool sample (faecal antigen test): this should be at least 4 weeks after eradication for PUD, gastric cancer of MALToma. 

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EMPIRICAL TREATMENT

  • Offer treatment to all patients newly diagnosed with H. pylori .
  • Do not use clarithromycin or metronidazole if patient has a history of use in the past year for any infection.
  • Do not retest or retreat for uninvestigated dyspepsia or functional dyspepsia

Empirical options for H pylori eradication

Durations
1st line and 2nd line therapy: 7 days
MALToma: 14 days

First line options - all options to be given orally (PO)

1st line

Penicillin allergy

Penicillin allergy and previous exposure to clarithromycin1

Lansoprazole electronic Medicines Compendium information on Lansoprazole 30mg 12-hourly
AND 
Amoxicillin electronic Medicines Compendium information on Amoxicillin 1g 12-hourly
AND EITHER
Clarithromycin electronic Medicines Compendium information on Clarithromycin 500mg  12-hourly
OR
Metronidazole electronic Medicines Compendium information on Metronidazole 400mg 12-hourly

Lansoprazole electronic Medicines Compendium information on Lansoprazole 30mg 12-hourly
AND 
Clarithromycin electronic Medicines Compendium information on Clarithromycin 500mg 12-hourly
AND 
Metronidazole electronic Medicines Compendium information on Metronidazole 400mg 12-hourly

Lansoprazole electronic Medicines Compendium information on Lansoprazole 30mg 12-hourly
AND 
Metronidazole electronic Medicines Compendium information on Metronidazole 400mg 12-hourly
AND
Doxycycline electronic Medicines Compendium information on Doxycycline 100mg 12-hourly
AND
Bismuth subsalicylate (Peptobismol) 525mg 6-hourly

Second line options - all options to be given orally (PO)

  • Offer to patients who still have symptoms after completing first-line eradication treatment

2nd line

Previous exposure to clarithromycin and metronidazole

Penicillin allergy

Penicillin allergy and previous exposure to a quinolone1

Lansoprazole electronic Medicines Compendium information on Lansoprazole 30mg 12-hourly
AND
Amoxicillin electronic Medicines Compendium information on Amoxicillin 1g 12-hourly
AND EITHER
Clarithromycin electronic Medicines Compendium information on Clarithromycin 500mg 12-hourly
OR
Metronidazole electronic Medicines Compendium information on Metronidazole 400mg 12-hourly (whichever was not used first line)

Lansoprazole electronic Medicines Compendium information on Lansoprazole 30mg 12-hourly
AND
Amoxicillin electronic Medicines Compendium information on Amoxicillin 1g 12-hourly
AND EITHER
Levofloxacin electronic Medicines Compendium information on Levofloxacin 250mg 12 hourly
OR
Doxycycline electronic Medicines Compendium information on Doxycycline 100mg 12-hourly

Lansoprazole electronic Medicines Compendium information on Lansoprazole 30mg 12-hourly
AND
Metronidazole electronic Medicines Compendium information on Metronidazole 400mg 12-hourly
AND
Levofloxacin electronic Medicines Compendium information on Levofloxacin 250mg 12 hourly

Lansoprazole electronic Medicines Compendium information on Lansoprazole 30mg po 12-hourly
AND
Bismuth subsalicylate (Peptobismol) 525mg 6-hourly
AND
Metronidazole electronic Medicines Compendium information on Metronidazole 400mg 12-hourly
AND
Doxycycline electronic Medicines Compendium information on Doxycycline 100mg 12-hourly

Third line options

Seek advice from Gastroenterology if failure of eradication with second line regimens (peptic ulcer disease or MALToma only).

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Provenance

Record: 1210
Objective:
Clinical condition:

Helicobacter Pylori Infection

Target patient group: Adults
Target professional group(s): Secondary Care Doctors
Pharmacists
Primary Care Doctors
Primary Care Nurses
Secondary Care Nurses
Adapted from:

Evidence base

Adapted from: NICE. Clinical Guideline [CG184) Gastro-oesophageal reflux disease and dyspepsis in adults: investigation and management. NICE 2014, London. https://www.nice.org.uk/guidance/cg184/chapter/1-recommendations?unlid=6240325232015794309#helicobacter-pylori-testing-and-eradication

  • North of England Dyspepsia Guideline Development Group (2004). Dyspepsia – managing dyspepsia in adults in primary care. Centre for Health Services Research report no 112 [online].Newcastle, University of Newcastle. Available from the World Wide Web: [Accessed 4th Aug 2006]
  • Delaney BC, Qume M, Moayyedi P, Logan RFA, Ford AC, Elliott C, McNulty C, Wilson S, Hobbs FDR. Helicobacter pylori test and treat versus proton pump inhibitor in initial management of dyspepsia in primary care: multicentre randomised controlled trila (MRC-CUBE trial). British Medical Journal 2008; 336: 651-654.
  • Fischbach L and Evans EL. Meta-analysis: the effect of antibiotic resistance status on the efficacy of triple and quadruple first-line therapies for Helicobacter pylori. Alimentary Pharmacology & Therapeutics. 2007; 26: 343-357.
  • Malfertheiner P, Megraud F, O’Morain C, Bazzoli F, El-Omar E, Graham D, Hunt R, Rokkas T, Vakil N, Kuiper EJ, The European Helicobacter Study Group (EHSG). Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report. Gut 2007; 56: 772-781.
  • Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096
  • Chey W et al. American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection. Am J Gastroenterol 2007;102:1808–1825

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.0

Related information

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