The American College of Gastroenterology Clinical Guideline, the Toronto Consensus, and the Maastricht V/Florence Consensus Report reflect that there is increased resistance of Helicobacter pylori to clarithromycin, and traditional triple therapy (clarithromycin + amoxicillin + proton pump inhibitors [PPIs]) should not be prescribed unless the rates of clarithromycin resistance are known to be < 15%.
Thus, quadruple 14 days therapy becomes a new standard. Clarithromycin (500 mg), amoxicillin (1 g), metronidazole (500 mg), and a PPI, all given twice a day, are recommended as first-line therapy. An alternative regimen is bismuth subsalicylate (2 tablets four times a day), metronidazole (500 mg three or four times a day), tetracycline (500 mg four times a day), and a PPI (twice a day). Patients on this regimen will need to be informed about bismuth-related stool darkening. Triple therapy with levofloxacin (500 mg once a day), amoxicillin (1 g twice a day), and a PPI (twice a day) is an alternative but not recommended as the best initial option. Posteradication testing should be performed in all patients, but no sooner than 4 weeks after completion of treatment. Eradication of Helicobacter pylori before starting nonsteroidal anti-inflammatory drugs (NSAIDs) has been shown to significantly reduce the incidence of ulcers and associated complications of bleeding.
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