Helicobacter pylori eradication in adults
Full Title of Guideline:
Guidelines on the Eradication of Helicobacter pylori in
Adult Patients
Author (include email and role):
Professor Atherton - Consultant Gastroenterologist
Nicola Fawcett – Specialist Clinical Pharmacist: Antimicrobials
and Infection Control
Dr Vivienne Weston – Consultant Microbiologist
Division & Speciality:
Gastroenterology
Scope (Target audience, state if Trust
Doctors, pharmacists, microbiology
wide):
Review date (when this version goes out
April 2021
of date):
Explicit definition of patient group
to which it applies (e.g. inclusion and
Diagnosis and treatment of Helicobacter pylori in adult patients
exclusion criteria, diagnosis):
Changes from previous version (not
applicable if this is a new guideline, enter
below if extensive):
Summary of evidence base this
guideline has been created from:
Diagnostic guidance added
Treatment duration amended
nd
New alternative 2 line regimen added
1. Recommended best practice based on clinical experience
of guideline developers
2. NICE Clinical Guidance No 184 (2014) Dyspepsia and
Gastro-oesophageal Reflux Disease. Available from:
http://www.nice.org.uk/guidance/cg184/ (accessed 01-1214)
3. Public Health England (2012) Test and Treat Helicobacter
pylori (HP) in Dyspepsia – Quick Reference Guide for
Primary care. Available from:
https://www.gov.uk/government/publications/helicobacterpylori-diagnosis-and-treatment (accessed: 01-12-14)
4. Malfertheiner P et al. (2017) Management of Helicobacter
pylori infection – The Maastrict V / Florence Consensus
Report. Gut; 66: 6-30
5. NICE Guidance NG12 (June 2015). Suspected Cancer:
recognition and referral. Available from:
https://www.nice.org.uk/guidance/ng12
Please note this guidance differs slightly from that published by
PHE due to expert opinion and experience of the guideline
developer.
This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or expert.
Caution is advised when using guidelines after the review date or outside of the Trust.
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Guidelines on the Eradication of Helicobacter pylori in Adult Patients
Background
This guideline is about the eradication of Helicobacter pylori. The gastric bacterium
H. pylori is widely present in the population but causes no harm in the majority of
patients. H. pylori prevalence is approximately 40% in the UK, though the prevalence
increases with age. There is now clear cut evidence that peptic ulcer disease (PUD)
may be cured by eradicating H. pylori. H. pylori eradication also resolves dyspeptic
symptoms in 10% of H. pylori-colonised dyspeptic patients without ulcers. It has no
role in treatment of gastric adenocarcinoma and whether it may slightly reduce the
risk of future cancer remains unclear. In the community, dyspeptic patients below the
age of 55 and with no alarm symptoms (see below) are often tested for H. pylori and
treated if positive, particularly if symptoms have not resolved or recurred after a
course of proton pump inhibitor therapy.
Diagnosis
Choice of investigation in a patient with suspected H. pylori should be determined
depending on patient specific factors and whether or not there are any alarm
symptoms present (see below). In patients with simple dyspepsia aged <55 without
alarm symptoms, endoscopy is not usually indicated and a non-invasive test is
appropriate, preferably a urea breath test. Some groups of dyspeptic patientswith
alarm symptoms should be referred for endoscopy on the two week wait system for
suspected cancer (see below). H. pylori can then be tested for by an endoscopic
biopsy-based test, usually a biopsy urease test. Most tests for H. pylori are only
reliable if the patient has had no antibiotics or bismuth compounds within 4 weeks
and proton pump inhibitors have been stopped for at least two weeks. The exception
is serology, but this is less accurate than other tests and often remains positive even
after successful treatment; thus it cannot be used to assess treatment success, even
in the distant past. The table 1 summarises the different diagnostic tests commonly
used, along with their advantages and disadvantages.
TABLE 1: TESTS COMMONLY USED TO DETECT HELICOBACTER PYLORI
Test
Advantages
Disadvantages
Tests Based on Endoscopic Biopsy
Biopsy urease test
Quick, simple
Some commercial tests not fully sensitive before 24
h
Histology
May give additional histologic information
Sensitivity dependent on experience and use of
special stains
Culture
Permits determination of antibiotic susceptibility
Sensitivity dependent on experience
Serology
Inexpensive and convenient; not affected by recent
antibiotics or proton pump inhibitors to the same extent as
breath and stool tests
Cannot be used for follow-up after treatment; some
commercial kits inaccurate, and most less accurate
than urea breath test
13
Inexpensive and simpler than endoscopy; useful for
follow-up after treatment
Requires fasting; not as convenient as blood or stool
tests
Stool antigen test
Note: not currently available at NUH
Inexpensive and convenient; useful for follow-up after
treatment; may be particularly useful in children
Note: not currently available at NUH
Stool-based tests are disliked by people from some
cultures
Noninvasive Tests
C urea breath test
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Current NICE guidelines for referral for upper GI endoscopy for suspected upper
gastrointestinal cancer
Urgent (within 2 weeks) referral for upper gastrointestinal endoscopy in patients with
:
 Dysphagia
 >55 years, with unexplained weight loss and:
o Upper abdominal pain
o Reflux
o Dyspepsia
Non-urgent referral for endoscopy in patients with
 Haematemesis (if not referred acutely for same day endoscopy, which would be
the normal recommended action)
 >55 years with:
o Treatment resistant dyspepsia
o Upper abdominal pain plus low haemoglobin
o Raised platelet count plus nausea or vomiting or weight loss or reflux
or dyspepsia or upper abdominal pain
o Nausea or vomiting plus weight loss or reflux or dyspepsia or upper
abdominal pain
Who requires treatment for the eradication of Helicobacter pylori?
Offer treatment to all patients newly diagnosed with H. pylori according to Table 2.
#
Do not use clarithromycin if the patient has history of use for any infection – go to
Table 3.
Helicobacter pylori Treatment Regimens
Table 2: First Line Treatment
1st Line:
If Penicillin allergic
Lansoprazole PO 30mg BD*
Lansoprazole PO 30mg BD*
Amoxicillin PO 1g BD
Metronidazole PO 400mg BD
Clarithromycin PO 500mg BD#
Clarithromycin PO 500mg BD#
For total
duration of
14 days
Table 3: Second Line Treatment – QUAD therapy
To be used after 1st line treatment failure or if patient has previously had
clarithromycin ~.
For total
Lansoprazole PO 30mg BD*
duration of 14
Bismuth salicylate (Pepto Bismol®) PO 262.5mg (2 chewable
days
tablets) QDS (see notes below)
Tetracycline HCl PO 500mg QDS
Metronidazole PO 400mg TDS
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Helicobacter pylori Treatment Regimens
Table 4: Alternative Second Line Treatment
To be used after 1st line treatment failure or if patient has had clarithromycin
prescribed in the last year ~.
If Penicillin allergic
Lansoprazole PO 30mg BD*
Lansoprazole PO 30mg BD*
Amoxicillin PO 1g BD
Metronidazole PO 400mg TDS
Levofloxacin PO 250mg BD
Levofloxacin PO 500mg BD
For total
duration of
10 days
Notes:
 * The proton pump inhibitor (PPI) may need to be continued at a ONCE daily
dose for 4 weeks, or until healing is complete for large or complicated
duodenal ulcers (DU) and all gastric ulcers (GU).
 # Do not use Clarithromycin if patient has history of use for any infection – go
to Table 2 or 3, and then in the case of treatment failure to the other of Table
2 or 3.

~ Whether to use the regimen 2 or 3 is personal choice. Regimen 3 is simpler
to take, but there is a theoretically higher risk of Clostridium difficile infection
which, while very low for any individual patient, may be important at a
community level. Thus the authors prefer regimen 2
Pepto Bismol®
 The use of Pepto Bismol® in the eradication of H. pylori is off-label and
the Trust policy on medicines used outside of their marketing
authorisation should be followed.
 It contains salicylates and therefore:
o do not use if patient has an allergy to aspirin / salicylates,
o the manufacturer recommends that it should not be given
concomitantly with aspirin or other salicylates.
 Common side effects include black stools and tongue.
Re-testing patients
All GU or DU patients should be retested for H. pylori at least 4 weeks after the end
of antibiotic treatment. Treated patients who did not have an ulcer should be retested if symptoms recur. A carbon-13 urea breath test (UBT) or a stool antigen test
should normally be used to retest patients. However, if they are having a further
endoscopy for any indication (for example all GU patients have repeat endoscopy to
ensure healing and exclude gastric adenocarcinoma) biopsy-based tests can also be
used. Note the PPI will need to be stopped at least 2 weeks, and any antibiotics or
bismuth compounds at least 4 weeks before H. pylori testing is carried out.
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What to do in eradication failure?


Reassess need for eradication.
In Gastro-Oesophageal Reflux Disease (GORD), or non-ulcer dyspepsia
patients with no family history of cancer or PUD, maintenance PPI may be
appropriate, after discussion with the patient.
Which patients should be referred for specialist Gastroenterologist advice?


Patients in whom the above drug regimens cannot be used due to antibiotic
hypersensitivity or contra-indications.
Patients who have received two courses of different antibiotic treatment,
remain H. pylori positive by stool antigen or urea breath test, and in whom
there is a clear indication for treatment.
How to refer patients?
Patients should be referred to Professor John Atherton, Consultant
Gastroenterologist for outpatient review and consideration of third line treatments or
H. pylori culture and susceptibility testing on his specialised endoscopy list.
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