ACG Guideline for Treatment of Helicobacter pylori Infection in Adults

What does the American College of Gastroenterology (ACG) recommend for the treatment of Helicobacter pylori infection in adults?

The ACG recommendations have several nuances, but their only strong recommendation is that adults who are treatment-naïve should receive optimized bismuth quadruple therapy. (Level of Evidence = 5)

The ACG convened a panel of clinical experts and methodologists (there is no mention of patients or primary care clinicians) to review the current evidence for the treatment of H pylori infection in adults. The panel weighed systematic reviews, meta-analyses, network meta-analyses, and individual randomized trials to answer 11 separate clinical questions. Similar to ACG’s other guidelines, it provides useful tables, algorithms, and charts. The authors made only one strong recommendation: in adults who were not previously treated, 14 days of optimized bismuth quadruple therapy, which consists of a proton pump inhibitor (PPI; standard dose twice daily), bismuth subcitrate (120–300 mg four times daily) or subsalicylate (300 mg four times daily), tetracycline (500 mg four times daily; do not substitute with doxycycline), and metronidazole (Flagyl; 500 mg three or four times daily) should be first-line treatment. The following are conditional recommendations for adults who are treatment-naïve:

• Triple therapy with rifabutin for first-line therapy
• Dual therapy with a potassium-competitive acid blocker (eg, vonoprazan [Voquezna]) plus amoxicillin

The ACG also had conditional recommendations for adults previously treated for H pylori who have persistent infection:

• If not treated with bismuth, prescribe optimized bismuth quadruple therapy
• If previously treated with PPI-clarithromycin triple therapy, prescribe optimized bismuth quadruple therapy
• If previously treated with optimized bismuth quadruple therapy, prescribe rifabutin triple therapy

The ACG recommends follow-up testing with urea breath testing, fecal antigen testing, or biopsy-based testing at least 4 weeks after completing therapy. It also recommends avoiding clarithromycin- and levofloxacin-containing regimens in the absence of demonstrated macrolide or quinolone susceptibility, respectively. The panel also found insufficient evidence for the use of high-dose PPIs, potassium-competitive acid blockers, or probiotics.

Study design: Practice guideline

Funding source: Foundation

Setting: Various (guideline)

Reference: Chey WD, Howden CW, Moss SF, et al. ACG clinical guideline: treatment of Helicobacter pylori infection. Am J Gastroenterol. 2024;119(9):1730-1753.