Failure of H. pylori eradication therapy in adults

Secondary Helicobacter pylori resistance to clarithromycin is common after failure of first-line therapy. Therefore, repeat treatment with a clarithromycin-containing regimen has a very low success rate (about 10%) and should be avoided, as should ad hoc combinations.

Access to appropriate second-line (salvage) therapies is limited, so their use should be confined to general practitioners with a special interest, or the patient should be referred for specialist care. The indications for therapy should be reaffirmed before proceeding (see Overview of indications for H. pylori testing and eradication therapy).

Evidence-based options for salvage therapy after treatment failure include quinolone-based triple therapy (first choice for salvage therapy), bismuth-based quadruple therapy (second choice for salvage therapy), and rifabutin-based triple therapy (third choice for salvage therapy). For patients with hypersensitivity to penicillins, use bismuth-based quadruple therapy for salvage therapy.

Salvage therapy is only occasionally guided by culture and susceptibility testing obtained from an endoscopic biopsy. Primary H. pylori resistance to levofloxacin has not yet been observed to be a problem in Australia, H. pylori resistance to amoxicillin is very low, and H. pylori resistance to tetracycline is almost nonexistent.

At the time of writing, there is no evidence to prefer the use of other proposed salvage therapies (including sequential, concomitant and hybrid therapies) over the established salvage therapies listed below.