Gastritis & H. pylori Infection — Treatment Guideline
Source: ACG Clinical Guideline: Treatment of Helicobacter pylori Infection — American Journal of Gastroenterology, 2024
Guideline: Strong
Guideline: Conditional
Guideline: Not recommended
ClinicoQ pathway suggestion (not from the cited guideline)
Diagnosis
Diagnostic criteria
Diagnosis is established by a positive H. pylori test (stool antigen, urea breath test, or endoscopic biopsy) in a patient with dyspepsia, peptic ulcer disease, or gastritis found on endoscopy.
⚠ Alarm features (investigate before diagnosing)
- GI bleeding or melena
- Unexplained iron deficiency anemia
- Unintentional weight loss
- Progressive dysphagia or odynophagia
- Recurrent vomiting
- Palpable abdominal mass
- Family history of GI cancer
Initial workup
| Test | When to order |
|---|---|
| Stool antigen test or urea breath test | First-line for patients under 60 without alarm features (test-and-treat). Stop PPI 2 weeks and antibiotics/bismuth 4 weeks before testing. |
| Upper endoscopy with biopsy | Age 60 or older, or any alarm feature present. |
| Confirmatory test of cure | At least 4 weeks after completing eradication therapy, for all treated patients. |
✕ Tests the guideline advises against
Serology (antibody) testing: No longer recommended — cannot distinguish active infection from past exposure; roughly as reliable as a coin toss for predicting active infection.
Treatment
Treatment-naive
1
Bismuth Quadruple Therapy (BQT)
Strong (Guideline recommendation)
- Dose
- PPI twice daily + bismuth subsalicylate/subcitrate 4x daily + tetracycline 500 mg 4x daily + metronidazole 500 mg 3–4x daily
- Duration
- 14 days
- Evidence level
- High
- Avoid if
- Penicillin/tetracycline allergy requires regimen adjustment; use bismuth cautiously in renal impairment
- If no response ClinicoQ pathway
- Confirm eradication at 4 weeks; if persistent, follow the treatment-experienced pathway
2
Rifabutin triple therapy or PCAB-amoxicillin dual therapy
Conditional (Guideline recommendation) — suitable alternative without penicillin allergy
- Dose
- Per product labeling
- Duration
- 14 days
- Evidence level
- Moderate
- Avoid if
- Penicillin allergy (for the amoxicillin-based option)
- If no response ClinicoQ pathway
- Proceed to the treatment-experienced pathway
Treatment-experienced (persistent infection)
1
Optimized Bismuth Quadruple Therapy
Strong (Guideline recommendation), if not previously tried
- Dose
- Same components as first-line BQT, optimized based on prior regimen used
- Duration
- 14 days
- Evidence level
- Moderate
- Avoid if
- Same precautions as first-line BQT
- If no response ClinicoQ pathway
- Rifabutin-based triple therapy
2
Rifabutin-based triple therapy
Conditional (Guideline recommendation)
- Dose
- Per product labeling, combined with PPI and amoxicillin
- Duration
- 14 days
- Evidence level
- Low
- Avoid if
- Known rifamycin hypersensitivity
- If no response ClinicoQ pathway
- Refer for antibiotic susceptibility testing and culture-guided therapy
✕ Treatments the guideline advises against
Clarithromycin-based triple therapy (as empiric first-line): Guideline recommends avoiding clarithromycin- or levofloxacin-based regimens unless susceptibility testing confirms effectiveness, due to rising resistance rates.
Concomitant therapy: Guideline: concomitant therapy is not suggested over Bismuth Quadruple Therapy.
⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.