Bismuth-based quadruple therapy in adults
An alternative option for H. pylori eradication salvage therapy is bismuth-based quadruple therapy. This regimen is often used after failure of quinolone-based triple therapy but may be used beforehand (eg for patients with hypersensitivity to penicillins). Use:
1esomeprazole 20 mg orally, twice daily for 7 or 14 days esomeprazole esomeprazole esomeprazole
OR
1lansoprazole 30 mg orally, twice daily for 7 or 14 days lansoprazole lansoprazole lansoprazole
OR
1omeprazole 20 mg orally, twice daily for 7 or 14 days omeprazole omeprazole omeprazole
OR
1pantoprazole 40 mg orally, twice daily for 7 or 14 days pantoprazole pantoprazole pantoprazole
OR
1rabeprazole 20 mg orally, twice daily for 7 or 14 days rabeprazole rabeprazole rabeprazole
PLUS
colloidal bismuth subcitrate 120 mg orally, 4 times daily on an empty stomach for 7 or 14 days1 colloidal bismuth subcitrate bismuth subcitrate bismuth subcitrate
PLUS
tetracycline 500 mg orally, 4 times daily on an empty stomach for 7 or 14 days2 tetracycline tetracycline tetracycline
PLUS
metronidazole 400 mg orally, 3 times daily with food for 7 or 14 days. metronidazole metronidazole metronidazole
There is no clear evidence of superiority for the longer duration of treatment. Reported success rates for this regimen are about 80 to 85%; pretreatment H. pylori resistance to metronidazole does not affect the results of this therapy. This regimen is complex and adverse effects are common (eg nausea, loose or discoloured stools, taste disturbance); clear explanation to the patient is needed to maximise adherence.