Gastrointestinal Disorders

Helicobacter pylori Treatment Guidelines

Antibiotic resistance is a global health threat and plays a role in the growing number of treatment-resistant organisms. Helicobacter pylori, for example, is one of those organisms.

Recently, a research team led by Carlo A. Fallone, MD, from McGill University Health Center in Montreal, Canada, reviewed guidelines developed by expert groups in Europe, Canada, and the United States for the treatment of H pylori infection.1

Consultant360 reached out to Dr Fallone to learn more about his team’s study and their findings.

Consultant360: Current H pylori treatment guidelines recommend bismuth for first-line treatment, which has replaced clarithromycin-based triple therapy. Why is bismuth a better option for patients?

Carlo Fallone: The problem with the clarithromycin-based triple therapies is the increased clarithromycin resistance, thus leading to a high treatment failure rate. This is avoided by using bismuth quadruple therapy as first-line treatment, as the latter does not contain clarithromycin.

Consultant360: What options are available if a patient is resistant to the medications used as first- and second-line treatments?

CF: The options available depend on what was used in first and second line. If clarithromycin was previously used, it should not be used in the salvage therapy, because the organism is surely resistant to that antibiotic. Bismuth quadruple or levofloxacin triple therapy can be used in that situation. If the latter two were also previously used, then one can try high-dose dual therapy. If that fails, rifabutin triple therapy. This is outlined in Figure 1 of our manuscript.

Consultant360: Do you think there is a lack of resistance testing available? If so, how can this be rectified?

CF: Yes, there is a lack of resistance testing. We need to encourage local availability of susceptibility tests as well as regional and national monitoring programs similar to what is available in Europe.

Consultant360: What is the most crucial research happening now among this patient population?

CF: Further development of stool-based molecular testing for antibiotic resistant organisms will render resistance-guided therapy easily available and practical. Development of narrow-spectrum therapeutics against H pylori specific targets will enable successful eradication without altering resistance patterns in other bacterial species. More potent acid inhibitors, such as potassium-competitive acid blockers, will likely increase eradication success. A vaccine against H pylori seems feasible, and further research on this is important.


  1. Fallone CA, Moss SF, Malfertheiner P. Reconciliation of recent Helicobacter pylori treatment guidelines in a time of increasing resistance to antibiotics. Gastroenterology. 2019;157(1):44-53.